Systems, methods, and devices for assisting or performing guided interventional procedures using custom templates

ABSTRACT

Systems, methods, and devices are provided for assisting or performing guided interventional procedures using custom templates. The system uses pre-procedure scans of a patient&#39;s anatomy to identify targets and critical structures. A template is then manufactured containing guide elements. During a procedure, the template may be aligned to the patient and instruments passed though the guide elements and into various targets. The template may be aligned using one or more of, for example, a position sensing system or a live imaging modality to register the patient to the template. The system makes optional use of devices designed to immobilize or track an organ during therapy.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/381,236, filed Apr. 11, 2019, which is a division of U.S. patentapplication Ser. No. 15/282,824, filed Sep. 30, 2016 (which issued asU.S. Pat. No. 10,265,137 B2 on Apr. 23, 2019), which is acontinuation-in-part of U.S. patent application Ser. No. 14/795,247,filed Jul. 9, 2015 (which issued as U.S. Pat. No. 9,681,919 B2 on Jun.20, 2017), which claims priority to U.S. Provisional Patent ApplicationNo. 62/022,203, filed Jul. 9, 2014, each of which is hereby incorporatedby reference herein in its entirety. U.S. patent application Ser. No.15/282,824 further claims priority to U.S. Provisional PatentApplication Ser. No. 62/234,765, filed Sep. 30, 2015, which is herebyincorporated by reference herein in its entirety.

FIELD OF THE INVENTION

The invention relates generally to guided interventional procedures, andmore particularly to systems, methods, and devices for assisting orperforming guided interventional procedures using custom templates.

BACKGROUND OF THE INVENTION

Many medical procedures rely on imaging for guidance of procedures,particularly those that are minimally invasive such as needleprocedures. Needle procedures are routinely performed to deliver drugs,take tissue samples, or perform therapy. Therapies may include, but arenot limited to, tissue ablation therapies such as radiofrequencyablation, cryoablation, photodynamic therapy, brachytherapy, radiation,laser and microwave ablation; implant of a device such as an artificialheart valve, stent, stent graft, feeding tube, catheter, radioactiveseed or electrode; establishment of a channel or pathway such as ashunt; bypass or closure or surgical resection of a portion of tissue;or to place a localization marker or fiducial that can then guidesubsequent surgery, radiation therapy etc. to the appropriate location.Many other minimally invasive therapies exist.

When performing these and other minimally invasive interventionalprocedures, it is important that a physician know the position andorientation of surgical instruments relative to the tissue of interest.While this is sometimes obvious (e.g., direct visualization of anobviously differentiated tissue type), it is often not. Sometimes,diseased tissue may not look different than normal surrounding tissue.Sometimes, an instrument's tip may not be directly visualized and,occasionally, the tissue may not be directly visualized at all. This isespecially true for minimally invasive procedures where it is desirableto create as small an entry as possible so structures and tissues ofinterest may never be visualized.

In many cases, these procedures may be carried out with the assistanceof volumetric imaging such as Computed Tomography (CT), MagneticResonance Imaging (MRI), or Positron Emission Tomography (PET). They mayalso be carried out using optical techniques including directvisualization through an endoscope, or through the use of some kind ofspectroscopy or fluorescence. Ultrasound imaging (US) and X-ray imagingare also used extensively.

Imaging modalities may also be used before an interventional procedureto plan the treatment or diagnostic procedure, or during theinterventional procedure itself to help locate the tissue and/orinstruments. X-ray, optical imaging, and US are often regarded asreal-time imaging modalities because they may be more portable andconvenient than volumetric modalities, and can be easily used during anintervention. In some cases, these imaging devices may not offer as muchinformation as volumetric modalities such as MRI. For example, certaintumors or anatomy that are visible on MRI may not be apparent on US orX-ray, or the quality may be insufficient.

Currently, accurate and easy targeting of a biopsy or therapy deviceinto a target site seen under volumetric methods once a patient has beenmoved out of the scanner, particularly a CT or MRI scanner, is achallenge since the live device position is not seen on the scans oncethe scans are complete. The same is true for Cone Beam ComputedTomography (CBCT) and other modalities. While it is possible to performan intervention in the scanner itself, this may be time consuming,inconvenient, and costly. Ultimately, while many minimally invasiveinterventions such as needle procedures do have pre-procedure volumetricimaging available, the procedure itself is performed with the assistanceof rudimentary imaging devices such as US or X-ray with thepre-procedure volumetric images available only as static films or on adisplay workstation.

In some cases, such as those performed under X-ray, the anatomy may bevisible only during injection of contrast and while the X-ray beam ison. This may expose the surgical team and patient to frequent doses ofionizing radiation and the patient to high doses of nephrotoxic contrastagents. Standard X-rays offer only two dimensional views requiringfrequent repositioning of the imager to ensure the instrument is in thecorrect 3D location in the anatomy.

In some instances, such as those performed using ultrasound (ormodifications of US such as Contrast Enhanced Ultrasound (CEUS), orultrasound elastography), the anatomy may be poorly visualized orpresented in a form that makes it difficult for a physician tointerpret. Some lesions or anatomy may not be suited to ultrasound atall so it is necessary to “mentally fuse” images frompreoperatively-obtained volumetric images with the live ultrasoundimages.

A physician may also have difficulty identifying a target on the livemodality that was previously seen on the preoperative images especiallyif they are of different modalities. In some cases, the lesion may becompletely invisible under a live modality.

Additionally, it is often desirable to perform a minimally invasiveprocedure to minimize chances of severe complications that sometimesaccompany surgery. By precisely targeting devices, focal cancer lesionstreatments, therapy or biopsy locations, it may be possible withoutsubjecting the patient to a large, invasive procedure that wouldotherwise be poorly tolerated. Only the diseased tissue may be targeted,and healthy tissue spared.

In most cases, the location of an instrument or device must be preciselyknown in order to properly treat a patient. For example, the locationand orientation of a heart valve delivered by a transapical approachmust be known prior to deployment. Other examples include placement ofbiopsy needles prior to sampling, placement of therapy devices as listedabove or devices such as implanted fiducials for marking of tumorboundaries for use in later surgery or radiation therapy. In some cases,needles or other instruments may be inserted to monitor therapy. Forexample, temperature sensors in the form of needles may be inserted tomonitor an ablation procedure. When a plurality of devices are implantedsuch as needles designed to sample multiple locations or ablate multipleportions of a tumor, it is important to accurately place each in adesired location to ensure the therapy is correctly administered.

Currently, needles and other minimally invasive devices may be directedto targets using techniques that may include freehand placement ofneedles, freehand image-guided needle procedures, needle guides,transperineal saturation guidance, stereotactic frames, robots, orcomputer assisted image guided intervention.

Needle procedures may be performed freehand and without the use ofimaging if the target is large or apparent, such as a large palpablelump or nodule, however image guidance is often preferred. During thetechnique of freehand needle procedures, needles are typically held in aphysician's hand and inserted into the lesion of interest.

Image-guided freehand procedures are similar except that, fromtime-to-time during the insertion process (or continuously in somecases), an X-ray, CT scan, US, MRI scan, etc. is used to ensure theneedle is properly approaching the target and is not impinging onsensitive structures. This is a very common type of needle procedure.For example, during freehand ultrasound-guided needle procedures, anultrasound transducer may be used to visualize the lesion and path. Aneedle is then introduced within the scan plane of the transducer sothat it can be visualized on its path toward the lesion. This approachmay be difficult if the target cannot be easily identified, and may betime consuming or use copious amounts of radiation or contrast agents ifX-ray imaging is used.

Another common approach uses “needle guides” that are employed duringsome ultrasound procedures. In this case, a special guide tube may beattached to an ultrasound transducer. This needle guide is positioned ina known orientation and location relative-to and in the scan plane ofthe probe, usually by a “click-on” alignment feature. Once attached tothe transducer, the paths of a needle placed into the guidance portionof the needle guide can be predicted along the specific path predefinedby the guide. The needle path is displayed on the ultrasound screen as afixed line, and this path is aligned with the lesion and the needleplaced into the target for biopsy, treatment, etc. An example of aneedle guide may be found in U.S. Pat. No. 8,073,529 to Cermak et al.which is hereby incorporated by reference herein in its entirety.

Prostate biopsy sometimes makes use of a Transrectal Ultrasound (TRUS).A TRUS probe may be positioned in a patient's rectum and a needle guidemay be attached to the probe. The tube on the needle guide is used todirect needles into lesions that can be visualized on the ultrasound or,more often, to ensure the needles are sampling within the prostate andnot elsewhere.

Needle guides are typically useful in cases where a target is readilyvisualized by ultrasound, and can restrict the approach (of a physicianto the target) to an approach that is in-plane with the viewing plane ofthe ultrasound. In the prostate, some experts have indicated thattransrectal approaches may lead to a greater incidence of infection, andtransperineal biopsies may be superior for prostate needle procedures.Needle guides would likely not be useful for Transperineal biopsies.

An alternate approach is a technique known as transperineal saturationbiopsy, a template consisting grid of regularly spaced parallel holesplaced externally adjacent to the perineum of the patient. A transrectalultrasound may be introduced and used to observe the sequentialplacement of needles through the holes in the grid. Needles are insertedinto each hole that covers part of the prostate in succession and asample of the tissue is taken.

Saturation biopsies can be expensive and time-consuming due to the largenumber of samples (e.g., typically at least sixty, and sometimes twicethat number) that are extracted and analyzed. They may also beuncomfortable for the patient.

In some cases, partial or “focal” transperineal biopsies may beperformed in which a subset of a saturation biopsy is used toselectively target certain locations within the prostate or tissue beingsampled. Based on a scan or other knowledge of the probable location ofthe cancer (such as the results of a prior biopsy), the suspected areamay be preferentially sampled. Even in these reduced biopsies, usuallyat least 30 biopsy cores are obtained.

Various robotically-assisted biopsy techniques are known, usingmulti-axis robots that serve as a needle aiming and holding devices.Based on preoperative volumetric scans, a robot is first registered to apatient. The needle held by the robot is then aligned to the targetautomatically. A physician delivers the needle to the target either byhand pushing the needle or by directing the robot to do so using anelectromechanical control mechanism.

Stereotactic biopsy has been used for many years. In this method, aframe is fitted to the patient, typically to the head, in order toobtain needle access to a lesion in the brain. The location of thetarget relative to the location of the frame is determined from scans,and a needle on the frame is aligned to the target using dials andprecise scales to move and angle the needle. It is then inserted in astraight path through a trephination or burr hole into the location inthe brain.

Various forms of stereotaxy exist, but the technique is currently mainlylimited to radiosurgery or radiotherapy using external radiation beamsas stereotactic frames, and needles are rarely used any more. Thetechnique is regarded as complex and fairly invasive, and has beenlargely replaced by computer assisted “frameless stereotaxy” (describedbelow).

The advent of accurate and inexpensive position sensors has enabledmethods of Image-Guided Interventions (IGI) (also known as “framelessstereotaxy”) to be used to bring an instrument to the location of atarget during an interventional procedure. Proper localization includingposition and orientation of these devices is critical to obtain the bestresult and patient outcome.

Some IGI systems use an externally placed locating device (also known astracking systems or position sensors), such as a camera system ormagnetic field generator together with an instrument containing atrackable component or “position indicating element” that can belocalized by a locating device or tracking system (collectively referredto hereinafter a “tracking device”). Depending on the device andtechnology, these use infrared light emitting diodes (LEDs), reflectivespheres, or small electromagnetic sensing coils as position indicatingelements.

Position indicating elements are associated with a coordinate system andare typically attached to instruments such as surgical probes, drills,microscopes, needles, X-ray machines, etc., and to the patient. Thespatial coordinates and often the orientation (depending on thetechnology used) of the coordinate system associated with the positionindicating elements can be determined by the tracking device in thefixed coordinate system (or fixed “frame of reference”) of the trackingdevice. Many tracking devices may be able to track multiple positionindicating elements simultaneously in their fixed frame of reference.Through geometrical transformations, it is possible to determine theposition and orientation of any position indicating element relative toa frame of reference of any other position indicating element tracked bythe same tracking device.

A variety of different tracking devices exist, having differentadvantages and disadvantages. For example, optical tracking devices maybe constructed to enable the highly accurate position and orientation ofa tool equipped with position indicating elements to be calculated. Anexample of an optical tracking device is the Polaris Vicra (NorthernDigital Inc., Waterloo, ON Canada). Optical tracking devices suffer fromline-of-site constraints, as they rely on triangulation of alight-emitting diode or reflective marker with several cameras.

An example of an Electromagnetic (EM) tracking device is the Aurora(Northern Digital Inc., Waterloo, ON Canada). EM tracking devices do notrequire a line-of-sight between the tracking device and the positionindicating elements. EM tracking devices may be used with flexibleinstruments where position indicating elements are placed at the tip ofthe instruments. Other known tracking devices include, but are notlimited to, mechanical linkage devices, fiber optic devices, ultrasonicdevices and global positioning devices.

Image guided interventions using these systems can be effectivelyperformed if an accurate “registration” is available to mathematicallymap the position data of position indicating elements expressed in termsof the coordinate system of the tracking device (“patient space”) to thecoordinate system of the externally imaged data (“image space”)determined at the time the images were taken. In rigid objects such asthe skull or bones, one method of registration is performed by using aprobe equipped with position indicating elements (therefore, the probeitself is tracked by a tracking device) to touch fiducial markers (suchas, for example, small steel balls (x-spots) made by the BeekleyCorporation, Bristol, CT) placed on the patient prior to imaging. Thisenables the system to obtain the patient space coordinates of thefiducials. These same fiducials are visible on an image such as, forexample, a CT scan and are identified in the image space by indicatingthem, for example, on a computer display. Once these same markers areidentified in both spaces, a registration transformation or equivalentmathematical construction can be calculated. In one commonly used form,a registration transformation may comprise a 4×4 matrix that embodiesthe translations, magnification factors and rotations required to bringthe markers (and thus the coordinate systems) in one space in tocoincidence with the same markers in the other space.

Fiducial markers used for registration may be applied to objects such asbone screws or stick-on markers that are visible to the selected imagingdevice, or can be implicit, such as unambiguous parts of the patientanatomy. These anatomical fiducials may include unusually shaped bones,osteophytes or other bony prominence, calcifications, features on bloodvessels or other natural lumens (such as bifurcations of bronchialairways), individual sulci of the brain, or other markers that can beunambiguously identified in the image and patient. A rigid affinetransformation such as the 4×4 matrix described above may require theidentification of at least three pairs of non-collinear points in theimage space and the patient space. Often, many more points are used anda best-fit may be used to optimize the registration. It is normallydesirable that fiducials remain fixed relative to the anatomy from thetime of imaging until the time that registration is complete.

Registration for image-guided surgery may be accomplished usingdifferent methods. Paired-point registration (described above) isaccomplished by a user identifying points in image space and thenobtaining the coordinates of the corresponding points in patient space.

Another type of registration, surface registration, can be done incombination with, or independent of, paired point registration. Insurface registration, a cloud of points is obtained in the patient spaceand matched with a surface model of the same region in image space. Abest-fit transformation relating one surface to the other may then becalculated. In another type of registration, repeat-fixation devices maybe used that involve a user repeatedly removing and replacing a devicein known relation to the patient or image fiducials of the patient.

Automatic registration may also be performed. Automatic registrationmay, for example, make use of predefined fiducial arrays or “fiducialshapes” that are readily identifiable in image space by a computer. Thepatient space position and orientation of these arrays may be inferredthrough the use of a position indicating element fixed to the fiducialarray. Other registration methods also exist, including methods thatattempt to register non-rigid objects generally through image processingmeans.

Registrations may also be performed to calculate transformations betweenseparately acquired images. This may performed by identifying “mutualinformation” (e.g., the same fiducial markers existing in each imageset). In this regard, information visible in one image, but not theother, may be coalesced into a combined image containing informationfrom both.

One such method for doing “image-image co-registration” for ultrasoundand MRI was presented by Xu et al in “Real-time MRI-TRUS Fusion forGuidance of Targeted Prostate Biopsies,” Computer Aided Surg., 2008September; 13(5): 255-264. Another method of registration ofpre-procedure and intra-procedure images is disclosed in U.S. patentapplication Ser. No. 13/918,413 to Glossop et al., filed Jun. 14, 2013,entitled “System, Method and Device for Prostate Diagnosis andIntervention,” each of which is hereby incorporated by reference hereinin its entirety. These methods include the co-registration or matchingof two sets of similar but non-identical three dimensional images. Theimages are not identical even when the same modality is used due to themovement of tissue and the patient between the times of the scans. Whenthe modalities differ (e.g., ultrasound and MRI), the images alsodiffer. Co-registration may take the form of rigid, affine, non-rigid(deformable) etc. methods, many of which are well known in the art andare a continuous area of research.

Once the images have been co-registered, a mapping is available that isable to take a point or region on one image set and transfer it to theother image set.

In certain implementations, the location of lesions, targets or regionsof interest may be copied or transferred on to other images. Forexample, if a region or target was detected on MRI, it may betransferred onto CT images, X-ray images, PET images, Ultrasound images,or other MRI images, for example. This may be done, for instance, byusing the aforementioned transformation to transform coordinates fromthe first image space to the second image space. This “combined imagespace” may in turn be registered to the patient space using thetechniques mentioned above.

Following registration, the two or more spaces are linked through thetransformation calculations. Spaces that may be linked may include forexample patient and image, image and image, or multiple images andpatient. Once registered, the position and orientation of a trackedprobe placed anywhere in the registered region may be located on, forexample, a scan or set of scans of the region. Likewise, it may bepossible to point to a location on one scan and have the matchinglocation be displayed on another scan.

When performing an intervention, a tracking device may be used.Typically the tracking device if used may be connected to a computersystem. Scans may also be loaded on to the computer system. The computersystem display may take the form of a graphical representation of aprobe or an instrument's position superimposed on to preoperative imagedata. Accordingly, it is possible to obtain information about the objectbeing probed as well as the instrument's position and orientationrelative to the object that is not immediately visible to the surgeon.The information displayed can also be accurately and quantitativelymeasured enabling the physician to carry out a preoperative plan moreaccurately.

In an image-guided intervention, it is desirable to plan the placementof a device or instrument in a precise pre-planned location (e.g.,defining both its location in three dimensions (e.g., its x, y, zlocation) as well as its orientation (roll, pitch, yaw)). Because of theinterdependence and coupling of orientation and translation, it istypically extremely difficult and tedious to manually align theinstrument with the preplanned location in all 6 degrees of freedom (alltranslations and rotations) simultaneously even with computer feedbackrelaying the distance from the planned positions and orientations. Assoon as some of the degrees of freedom are aligned, attempts to alignsubsequent rotations or translations cause the other degrees of freedomto fall out of alignment. While it is usually possible to converge onthe correct alignment, it may take some time to do so. It is also notintuitive as to how to move the probe to easily achieve this alignment.

An additional concept in image-guided intervention is that of “dynamicreferencing”. Dynamic referencing may account for any bulk motion of theanatomy or part thereof relative to a tracking device. This may entailattachment of additional position indicating elements to the anatomy, orother techniques. For example, in cranial surgery, position indicatingelements that form the dynamic reference are often attached directly tothe head or more typically to a clamp meant to immobilize the head. Inprostate surgery, a special Foley catheter may be used to track theprostate with the use of a position indicating element embedded in thecatheter (see U.S. Pat. No. 8,948,845 to Glossop et al., entitled“System, Methods, and Instrumentation for Image Guided ProstateTreatment,” which is hereby incorporated by reference herein in itsentirety). In spine surgery, a dynamic reference attached (via atemporary clamp or screw) to the vertebral body undergoing therapy isused to account for respiratory motion, iatrogenic motion, as well asmotion of the tracking device.

“Gating” may also be used to account for motion of the anatomy. Ratherthan continually compensating for motion through dynamic referencing,“gated measurements” are measurements that are only accepted atparticular instants in time. Gating has been used in, for example,cardiac motion studies. Gating synchronizes a measured movement (e.g.,heartbeat, respiration, or other motion) to the start of the measurementin order to eliminate the motion. Measurements are only accepted atspecific instants. For example, gating during image guided interventionof the spine may mean that the position of a tracked instrument may besampled briefly only during peak inspiration times of a respiratorycycle.

Both registration and use of an image guided intervention system in thepresence of anatomical motion (such as that which occurs during normalrespiration) is generally regarded as safer and more accurate if adynamic reference device is attached prior to registration (and/or ifgating is used). Instead of reporting the position and orientation of aposition indicating element of a tracked instrument in the fixedcoordinate system of the tracking device, the position and orientationof the position indicating element of the tracked instrument is reportedrelative to the dynamic reference's internal coordinate system. Anymotion experienced mutually by both the dynamic reference and thetracked instrument is “cancelled out.”

With reference to FIG. 1 , an organ 101 is depicted (e.g., a prostategland, kidney, liver, thyroid, or other organ) containing a suspectedtumor 102. Tumor 102 may be have been detected by an imaging modalitysuch as MRI multiparametric MRI, CT, PET, ultrasound, or by some othermethod. Once detected, it may be desirable to place a needle into tumor102 for the purposes of biopsy, therapy, or delivering fiducials, forexample.

The article by Pinto et al., entitled “Magnetic ResonanceImaging/Ultrasound Fusion Guided Prostate Biopsy Improves CancerDetection Following Transrectal Ultrasound Biopsy and Correlates withMultiparametric Magnetic Resonance Imaging,” The Journal of Urology,Volume 186, Issue 4, 1281-1285, which is hereby incorporated byreference herein in its entirety, demonstrates the use ofmultiparametric MRI in the detection of prostate cancer. Once it isvisualized on an imaging modality such as MRI, it may be annotated onthe MRI scans. It may also, for example, be segmented so that its threedimensional boundaries are visible on the scans. The suspected cancerregions may be marked as single points, as indicated by asterisk (*)point 103. The spatial location, size, and/or orientation may also bemodeled or notated and stored in a database or in reference to theimages on which it was detected.

In some instances, an organ or region may be segmented or delineated sothat its boundaries are apparent. This may assist a physician inunderstanding the boundaries of the organ. It may further assist inregistering the position and orientation of the organ with subsequentimages of the organ and, for example, enable it to be projected or fusedinto images obtained using another imaging modality. For instance, athree-dimensional graphic rendering representing a prostate gland thathas been segmented from MRI may be fused with a real-time imagingmodality such as ultrasound rather than the actual MRI images. Theorgan, in addition to critical structures within or around the organsuch as important vessels, nerves, ducts, stones, bones, valves, nodes,and other regions of interest may be segmented.

As shown in FIG. 1 , a number of needles 104 a, 104 b, 104 c, and 105are shown converging onto the tumor, specifically suspected cancerregion 103. The needles may be positioned for the purposes of samplingtissue (e.g., for a biopsy) or delivering a treatment as mentionedpreviously. Both the position and orientation of the needles areimportant so that while needles 104 a, 104 b, and 104 c may beacceptably placed, needle 105 may transect a structure 106 (e.g., suchas the urethra) which may not be acceptable. Using the methods explainedabove, a physician would attempt to avoid this structure. For example,in a transperineal saturation biopsy of the prostate, a physician mayuse imaging to constantly monitor for a needle that will violate theurethra.

In a prior art depiction shown if FIG. 2 , a needle 201 is equipped withan electromagnetic tracking sensor or position indicating element 202that, when connected to a position sensor 203, enables its location andorientation in space to be detected. Position sensor 203 may determinethe location of position indicating element 202 in a frame of reference204 so that a transformation matrix “[T0]” may be reported thatdetermines a translation and rotation to locate position indicatingelement 202 (and thus the tip of needle 201) in frame of reference 204.Similar devices have been disclosed previously for example in U.S. Pat.No. 6,785,571 to Glossop, entitled “Device and method for registering aposition sensor in an anatomical body,” which is hereby incorporated byreference herein in its entirety.

A registration step may be performed to relate the position of theactual anatomy 206 in frame of reference 204 with the images 207 of theanatomy. This transformation is indicated as “[T1]” in FIG. 1 . Thisenables a graphic display 209 of the needle on the pre-procedure images207, which moves around as the needle 201 is moved. Needle 201 may thenbe placed into the lesions or suspected lesions 210 by observing thegraphic display 209 of the needle while manipulating the actual needle201. When the graphic display 209 of the needle is shown to be in thecorrect trajectory, needle 201 may be placed into the anatomy 206 andsubsequently into lesion 210. There are numerous ways to perform thisregistration to obtain T1, some of which are referenced above.

In some implementations, an ultrasound, X-ray, or other live imagingmodality may be used in conjunction with the pre-procedure images. Inone implementation, an ultrasound transducer 211 may be equipped with aposition indicating element 212 that indicates the position andorientation of transducer 211 relative to frame of reference 204,indicated here as transformation “T2.” If a calibration has beenperformed, the location and orientation of the scan plane 214 oftransducer 211 is known as a fixed transformation “T3.” From this,points in the anatomy 206 on the scan plane 214 together withtransformations T1, T2, and T3 can yield the location of these points onpre-procedure images 207, and it is possible to fuse the preoperativeimages with the live images. If the location of needle 201 is knownthrough transformation TO, it too can be projected on the preoperativeand intraoperative images.

Methods of ultrasound calibration to determine T3 are known in the art,some of which are summarized in the document to Gee et al., entitled “3DUltrasound Probe Calibration Without A Position Sensor,” CUED/FINFENG/TR488, September 2004 (Cambridge University, Department Of Engineering,Trumpington Street, Cambridge CB2 1PZ, United Kingdom), and in thedocument to Lindseth et al., entitled “Probe Calibration for Freehand3-D Ultrasound,” each of which is hereby incorporated herein byreference in its entirety.

Templates or guides have been used in orthopedic surgery as well as anumber of commercial manufacturing procedures that require cutting,drilling or assembly operations. Templates are guides that include guideelements such as holes and slits that are placed in a precise locationover a work piece. Tools such as saws or drill are used to create holesor cuts in the work piece by first attaching the template to the workpiece, and then placing the tools into the guide elements of thetemplate and performing the cutting or drilling operation. The elementsin the template are defined a priori so that if the work piece isproperly aligned, the holes and cuts will be in the correct location.

In instances relating to orthopedic surgery, patient-specific templateshave been employed. For example, U.S. Pat. No. 8,956,364 to Catanzariteet al., entitled “Patient-Specific Partial Knee Guides and OtherInstruments” describes a cutting guide that differs from standardcutting guides used for total knee arthroplasty because it uses atemplate that is custom machined to the contours of the patient's boneto help align it. It is placed into the best matching position on thebone and, once in place, it may be used to guide the cuts in the bonedirectly or assist in mounting one or more cutting guides.

Medical templates are used exclusively for hard tissues, such as bone,since they can be aligned against hard immovable features on the bone.Unfortunately, soft tissues are not amenable to alignment usingtemplates in the same way as bone, because templates cannot engage (andtherefore be affixed to) soft tissues. These and other drawbacks exist.

SUMMARY OF THE INVENTION

The invention addressing these and other drawbacks in the art relates tosystems, methods, and devices for assisting or performing guidedinterventional procedures using custom templates.

According to an aspect of the invention, pre-procedure scans of apatient's anatomy may be used to identify targets and criticalstructures. A template is then manufactured containing one or more guideelements. During a procedure, the template may be aligned to thepatient, and instruments may be passed though the guide elements, andinto various targets. The template may be aligned using one or more of,for example, a position sensing system or a live imaging modality toregister the patient to the template. The system makes optional use ofdevices designed to immobilize or track an organ during therapy.

One advantage of the invention is that the systems, methods, and devicesdescribed herein facilitate procedures that require the localization ofone or more surgical instruments relative to soft tissue anatomy.

An additional advantage of the invention is that the systems, methods,and devices described herein facilitate procedures that may benefit fromthe placement of individualized templates to guide interventions orbiopsies, particularly where multiples needles or devices must be placedinto specific locations within a tissue.

Yet another advantage of the invention is that the templates describedherein may increase accuracy and speed an operation such as drilling orcutting. Once a template is in place, multiple operations may beperformed at once without the need to realign the template since thetemplate may contain several guiding elements or features.

These and other objects, features, characteristics, and advantages ofthe systems, methods, and devices disclosed herein, as well as themethods of operation and functions of the related elements of structureand the combination of parts and economies of manufacture, will becomemore apparent upon consideration of the following description and theappended claims with reference to the accompanying drawings, all ofwhich form a part of this specification, wherein like reference numeralsdesignate corresponding parts in the various figures. It is to beexpressly understood, however, that the drawings are for the purpose ofillustration and description only and are not intended as a definitionof the limits of the invention. As used in the specification and in theclaims, the singular form of “a”, “an”, and “the” include pluralreferents unless the context clearly dictates otherwise.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts needles targeted toward a suspected lesion in an organ,including a needle that traverses a sensitive structure.

FIG. 2 illustrates a prior art system in which an ultrasound equippedwith position indicating elements is used together with a needlecontaining a position indicating element to place a needle in apatient's anatomy.

FIG. 3 is a schematic view of an exemplary system for assisting orperforming guided interventional procedures using custom templates,according to an aspect of the invention.

FIG. 4 is an exemplary schematic representation of a template, accordingto an aspect of the invention.

FIG. 5 is an exemplary depiction of a template used to guide instrumentsto predefined locations in an organ, according to an aspect of theinvention.

FIG. 6 is a schematic representation of a template with a positionindicating element and fiducials attached, according to an aspect of theinvention.

FIG. 7 is an exemplary depiction of a template composed of two plates,according to an aspect of the invention.

FIG. 8 illustrates an oblong (or elliptical) opening in a template plateto facilitate a non-perpendicular passage of a cylindrical instrumentthrough the plate, according to an aspect of the invention.

FIG. 9 is an exemplary depiction of a template used in a guidedinterventional procedure, according to an aspect of the invention.

FIG. 10 illustrates how variations on an entry hole on a template may beused to sample a region around a target location, according to an aspectof the invention.

FIGS. 11A-11C are exemplary depictions of a deployable restrainingdevice that can restrain tissue and also serve to track its motion,according to an aspect of the invention.

FIG. 12 is an exemplary depiction of a catheter including aposition-indicating element that can be used to track motion of a tissueor organ, according to an aspect of the invention.

FIG. 13 is an exemplary flowchart of processing operations for creatingand using a template in a guided interventional procedure, according toan aspect of the invention.

FIGS. 14A-14D are exemplary depictions of method steps for positioning atemplate, and for generating paths through the template, according to anaspect of the invention.

FIG. 15 is an exemplary depiction of a template with an extension postthat may assist in positioning of the template in a planned position andorientation, according to an aspect of the invention.

FIGS. 16A-16F depict exemplary user interfaces for aligning a templateto a preplanned position and orientation, according to an aspect of theinvention.

FIG. 17 is an exemplary depiction of a membrane used in a guidedinterventional procedure, according to an aspect of the invention.

FIG. 18 is an exemplary depiction of a membrane used in a guidedinterventional procedure, according to an aspect of the invention.

FIG. 19 is an exemplary depiction of a fiducial array used in a guidedinterventional procedure, according to an aspect of the invention.

FIG. 20 is an exemplary depiction of a fiducial array and template usedin a guided interventional procedure, according to an aspect of theinvention.

FIG. 21 is an exemplary flowchart of processing operations for using afiducial array and a template in a guided interventional procedure,according to an aspect of the invention.

FIG. 22 is an exemplary depiction of a method of performing a guidedinterventional procedure with a template absent during a scan, accordingto an aspect of the invention.

FIG. 23 is an exemplary flowchart of processing operations forregistering and manufacturing templates, according to an aspect of theinvention.

FIGS. 24A and 24B are exemplary depictions of a needle assembly that maybe used with a template during a guided interventional procedure,according to an aspect of the invention.

FIGS. 24C and 24D illustrate respective side and oblique views of astabilizing device, according to an aspect of the invention.

FIG. 24E is an exemplary illustration of a stabilizing device coupled toa (cannula of a) needle assembly, according to an aspect of theinvention.

FIGS. 25A-25F are exemplary depictions illustrating the use of a needleassembly with a template during a guided interventional procedure,according to an aspect of the invention

DETAILED DESCRIPTION OF THE INVENTION

Described herein are systems, methods, and devices for assisting orperforming guided interventional procedures using custom templates forthe purpose of, among other things, marking or annotating regions,providing therapy to a region, sampling an aspect of a region, orcutting or manipulating a region.

Examples of guided interventional procedures may include, but are notlimited to, procedures such as surgical resections, biopsies, full orfocal ablation of a tumor or tissue, injection of an agent such as adrug, placement of fiducials, placement of brachytherapy seeds, markingor resection of the skin in preparation for a surgical procedure,marking or resection of an aspect of anatomy that is either a target ora critical location that must be avoided, placing monitoring sensorssuch as temperature sensors, placing stabilizing instruments, placementof devices such as stents or stent grafts, and placement of cardiacvalves or other such devices. Guided interventional procedures may alsoinclude marking and manipulation of tissues or fragments thereof.

Guided interventional procedures may further make use of therapeuticdevices such as, for example, needles, ablation needles, radiofrequencyablation needles, lasers and laser delivery systems, blades,cryoablation needles, microwave ablation needles, HIFU delivery systems,and radiation delivery devices, as well as various other therapeuticdevices. Such procedures may also make use of monitoring probes formeasuring temperature or dose, etc. Such procedures may further make useof probes that perform a protective function such as cooling an areathat is adjacent to a region that is being ablated using heat, etc.

Exemplary System Configuration

FIG. 3 is a schematic view of an exemplary (and non-limiting) system 300for assisting or performing guided interventional procedures usingcustom templates, according to an aspect of the invention.

System 300 may include a computer device 301, a tracking device 302, animaging device 303, a template assembly 312, one or more surgical deviceor surgical device assemblies 314, a dynamic reference device 315, orother components.

Computer Device 301

Computer device 301 may be or include one or more servers, personalcomputers, portable (e.g., laptop) computers, mobile computers, tabletcomputers, cell phones, smart phones, PDAs, or other computer devices.Computer device 301 may send, receive, store, or manipulate datanecessary to perform any of the processes, calculations, imageformatting, image display, or other processing operations describedherein. Computer device 301 may also perform any processes,calculations, or processing operations necessary for the function of thedevices, instruments, or other system components described herein.

Computer device 301 may include one or more processor(s) 304, one ormore storage device(s) 305, a power source 306, a control application307 comprising computer program instructions, one or more inputs/outputs309 a-309 n, at least one display device 310, one or more user inputdevices 311, or other components.

Processor(s) 304 may include one or more physical processors that areprogrammed by computer program instructions that enable various featuresand functionality described herein. For example, processor(s) 304 may beprogrammed by control application 307 (described below) and/or otherinstructions.

Storage device 305 may comprise random access memory (RAM), read onlymemory (ROM), and/or other memory. The storage device may store thecomputer program instructions to be executed by processor(s) 304 as wellas data that may be manipulated by processor(s) 304. Storage device 305may also comprise floppy disks, hard disks, optical disks, tapes, orother storage media for storing computer-executable instructions and/ordata.

Display device 310 may comprise a computer monitor or other visualdisplay device such as, for example, an LCD display, a plasma screendisplay, a cathode ray tube display, or other display device.

Input device 311 may comprise a mouse, a stylus, a keyboard, atouchscreen interface (which may be associated or integrated withdisplay device 310), a voice-activated input device (e.g., including amicrophone and/or associated voice processing software), or other devicethat enables a user (e.g., a physician performing a procedure, anassistant thereto, or other user) to provide input to computer device301 and/or other components of system 300. One or more input devices 311may be utilized. In one implementation, display device 310 and inputdevice 311 may together be configured as a mobile computing platformsuch as a tablet computer that is connected wirelessly to computer 301.Other configurations may be implemented.

Inputs/outputs 309 a-309 n enable various system components such astracking device 302, imaging device 303, template assembly 312, one ormore surgical device or surgical device assemblies 314, dynamicreference device 315, or other components to communicate with computerdevice 301 (e.g., in a wired or wireless manner) as known and understoodby those having skill in the art.

Although not illustrated in FIG. 3 , computer device 301 may beconnected to other computer devices and/or other system components via anetwork, which may include any one or more of, for instance, theInternet, an intranet, a PAN (Personal Area Network), a LAN (Local AreaNetwork), a WAN (Wide Area Network), a SAN (Storage Area Network), a MAN(Metropolitan Area Network), a wireless network, a cellularcommunications network, a Public Switched Telephone Network, and/orother network.

Computer device 301 may further be operatively connected (e.g., via theaforementioned network) to one or more databases. A database may be,include, or interface to, for example, an Oracle™ elational databasesold commercially by Oracle Corporation. Other databases, such asInformix™, DB2 (Database 2) or other data storage, including file-based,or query formats, platforms, or resources such as OLAP (On LineAnalytical Processing), SQL (Structured Query Language), a SAN (storagearea network), Microsoft Access™ or others may also be used,incorporated, or accessed. The database may comprise one or more suchdatabases that reside in one or more physical devices and in one or morephysical locations. The database may store a plurality of types of dataand/or files and associated data or file descriptions, administrativeinformation, or any other data, as described herein.

Tracking Device 302

In some implementations, tracking device 302 may be used. Trackingdevice 302 may comprise, for example, an electromagnetic tracker, anoptical tracker, a GPS tracker, an acoustic tracker, a mechanicaltracking system, or other tracking device.

Imaging Device 303

Imaging device 303 may include X-ray equipment, computerized tomographyequipment, positron emission tomography equipment, magnetic resonanceimaging equipment, fluoroscopy equipment, ultrasound equipment, anisocentric fluoroscopic device, a rotational fluoroscopic reconstructionsystem, a multi-slice computerized tomography device, an intravascularultrasound imager, an optical coherence tomography (OCT) device, anoptical imaging device, a single photon emission computed tomographydevice, a magnetic particle imaging device, or other imaging/scanningequipment.

In some implementations, imaging device 303 may include one or moredevices so that its location and orientation may be tracked by trackingdevice 302. For example, an ultrasound device may include aposition-indicating element enabling its scan plane to be known as shownin FIG. 2 . Similarly, a fluoroscope may include a tracking target suchas that described in U.S. Pat. No. 8,046,052 to Verard et al., andillustrated in U.S. Design Pat. No. D466,609 to Glossop, each of whichis hereby incorporated herein by reference in its entirety.

Template Assembly 312

According to an aspect of the invention, template assembly 312 maycomprise a template (also referred to as a targeting template or guide)and a position-indicating element or template tracker 313, which may beattached (permanently or removably) to the template or to a frame thatsurrounds (or encompasses) all or a portion of the template. Templatesare described in greater detail herein.

Template tracker 313 may comprise a mechanical encoder, or an optical,electromagnetic, or other tracker (described in greater detail below)that can be tracked by tracking device 302.

Further, although not illustrated in FIG. 3 , the template assembly mayfurther comprise a support mechanism or structure used to support and/orposition the template assembly vis-à-vis a target (e.g., a patient'sanatomy). The support mechanism may comprise dials or other controls toadjust and fine tune the position of the template. Examples of a supportmechanism may include a Biojet (D&K Technologies GmbH, Barum Germany) orthe Multi-purpose Workstation LP (Civco Inc., Coralville IA) that mayinclude motors and/or encoders. In one implementation, the templateassembly may be supported and/or moved into position in an automatedmanner using a robotic mechanism attached to the support mechanism.

Surgical Devices or Device Assemblies 314

In some implementations, system 300 may include one or more surgicaldevices or device assemblies 314, the position and orientation of whichmay be tracked by tracking device 302. Examples of surgical devices mayinclude therapeutic devices such as needles, ablation needles,radiofrequency ablation needles, lasers and laser delivery systems,blades, cryoablation needles, microwave ablation needles, HIFU deliverysystems, and radiation delivery devices, or other therapeutic devices.Monitoring probes for measuring temperature or dose, etc. may also beused along with probes that perform a protective function such ascooling an area that is adjacent to a region that is being ablated usingheat, etc. In some implementations (described in greater detail below),needles may further serve as elements that also restrain the anatomyfrom motion.

Dynamic Reference Device 315

In one implementation, system 300 may include a dynamic reference device315 capable of tracking a patient's anatomy. Examples of dynamicreference device 315 may include, but are not limited to, a trackedFoley catheter, a skin patch (e.g., as described in U.S. Pat. No.7,751,868 to Glossop which is hereby incorporated by reference herein inits entirety), a tracked needle, a K-wire (e.g., as described in U.S.Pat. No. 7,840,254 to Glossop which is hereby incorporated by referenceherein in its entirety), etc.

Control Application 307

As previously noted, computer device 301 may host control application307. Control application 307 may comprise a computer softwareapplication that includes instructions that program processor(s) 304(and therefore computer device 301) to perform various processingoperations.

In one implementation of the invention, control application 307 maycause computer device 301 to send, receive, and/or manipulate dataregarding the anatomy of a patient, one or more objects, or other data.This data may be stored in memory device 305, or in another data storagelocation (e.g., the one or more databases described above). In someimplementations, computer device 301 may receive live data (inreal-time), or stored data. Computer device 301 may send, receive,and/or manipulate data regarding the location, position, orientation, orcoordinate(s) of a position indicating element (e.g., sensor coils orother position indicating elements), or one or more other elements,received by tracking device 302. This data may also be stored in memorydevice 305 or in another data storage location (e.g., the one or moredatabases described above).

Control application 307 may further cause computer device 301 toproduce, format, reformat, or otherwise manipulate one or more images,position/orientation/location data, or other data. Images may bedisplayed on display device 310. In some implementations, one or morelive images may be displayed. Display device 310 may further display (orotherwise convey) audio data in addition to, or instead of, visual data.Such an audio display may produce tones or other indicators regardingthe system.

Control application 307 may additionally cause computer device 301 togenerate and display images of the anatomy of a patient along with theposition or orientation of an instrument, fiducials, or both (or otherinformation) superimposed thereon in real-time such that motion of thetracked instrument within the anatomy of the patient is indicated on thesuperimposed images for use in an image-guided procedure.

In some implementations, indicators (e.g., markings, lines, circles,spheres, letters, numbers or other indicators) may be produced on animage of the anatomy of a patient. These indicators may mark or identifyfeatures such as the boundaries of another image stored in memory device305.

In some implementations, control application 307 may facilitate mappingof a target lesion (e.g., a cancerous region) or other portion of apatient's anatomy, or other operations related to a map of the targetlesion or portion of the patient's anatomy. For example, controlapplication 307 may generate and display (e.g., on display device 310)the position of a targeting template relative to a location in a targetlesion, a projected path (of the target paths of the targeting template)including a path a needle or other instrument inserted into a hole ofthe targeting template will follow if the needle or instrument isextended past a distal end portion of the template. Control application307 may additionally generate and display (e.g., on display device 310)a point at which a needle or other instrument placed in a hole of thetemplate will intersect a target lesion if the projected path of theneedle or instrument intersects the determined path of the targetlesion, as well as an indicator of the closest approach from a needle orother instrument passing through a hole in the template to the targetlesion if the projected path of the needle or instrument does notintersect tissue not intended to be treated or biopsied. Additionaldisplays may be presented.

The foregoing system architecture is exemplary only, and should not beviewed as limiting. The invention described herein may work with varioussystem configurations. Accordingly, more or less of the aforementionedsystem components may be used and/or combined in variousimplementations. For example, in FIG. 3 , as well as in other drawingFigures, different numbers of entities than those depicted may be used.

Templates

FIG. 4 is an exemplary depiction of a template 400 (which may also bereferred to interchangeably herein as a “targeting template” or“guide”), according to an aspect of the invention.

In one implementation, template 400 may comprise a solid block ofbiocompatible material such as, for example, glass, stainless steel,titanium, plastics such as polycarbonate, delrin, polyethylene,polyetheretherketone (PEEK), ethylene vinyl acetate, polyphenylsulfone(PPSU), polysulfone (PSU), acrylonitrile butadiene styrene (ABS), orother material. In some implementations, template 401 need not comprisea biocompatible material if it is suitably draped (or otherwise covered)in a sterile barrier material. Although depicted as a square in FIG. 4 ,template 400 may have any shape. Template 400 may also comprise a curvedor contoured structure.

As shown in FIG. 4 , template 400 may comprise one or more guideelements 402 that extend through the body of template 400. For ease ofexplanation, a guide element 402 may be referred to throughout thisdetailed description as a “hole.” It should be appreciated, however,that other similar descriptors may be used in lieu of “guide element”including, but not limited to, a trajectory, passage, or channel.Further, as used herein, a pair of holes (or openings) may be describedas defining an instrument trajectory or channel. For example, a firstchannel that enables passage of a first medical device through a body oftemplate 400 may be defined by a first channel opening (or entrance orhole) on a first side of the template body and a corresponding firstchannel opening (or exit or hole) on a second side of the body oftemplate 400. Likewise, a second channel that enables passage of asecond medical device through the body of template 400 may be defined bya second channel opening (or entrance or hole) on the first side of thetemplate body and a corresponding second channel opening (or exit orhole) on the second side of the body of template 400, and so on. In someimplementations, template 400 may have multiple channels for enablingpassage of multiple medical devices through the template body.

In some implementations, one or more of holes 402 may be used fordifferent purposes. For example, some holes may comprise definedinstrument trajectories, such that instruments passing through template400 would follow the trajectory of the holes 402. Some holes may be usedfor therapy devices, such as thermal ablation instruments, whileadjacent holes may be used for placing devices for monitoringtemperature (such as thermocouples), or even cooling devices to protectsensitive tissue from thermal damage. Still other holes may be used toinject therapeutic agents, etc. Although described and illustrated asholes for ease of reference, trajectories (or passages or channels) 402may have any cross-section.

One or more holes 402 may be drilled into template 400 at variousorientations. In one implementation, the holes 402 may be created usinga Computer Numerical Control (CNC) drilling or milling machine.Alternatively, the holes may be made using electrical dischargemachining or any other type of technology designed to bore or createholes. In one implementation, template 400 and holes 402 may be createdusing an additive technology such as a three-dimensional (3D) printingsystem of which multiple technologies exist.

In an implementation, template 400 may further comprise one or morelocating features 403 such as channels, divots, holes, etc. Locatingfeatures 403 may be used to position template 400, or assist in mountingitems to template 400.

According to an aspect of the invention, one or more cutting guides 404may be cut into template 400 at various orientations using thetechnologies listed above. One or more cutting guides 404 may be used tohelp position a blade or saw or other flat cutting or therapy device.Although depicted in FIG. 4 as straight, cutting guide 404 may form astraight or curved path in the block through which instruments may beguided to help perform an interventional procedure in a patient byguiding the instruments.

Template 400 may further comprise one or more fiducial features (orregistration features, or fiducial markers, or “fiducials”) 405 for useas a point of reference or a measure. Fiducial features 405 may comprisegrids, holes, cuts, or markings (having any number of shapes) that maybe designed to be visible under an imaging modality. Such features maybe visible when viewed by the imaging equipment alone. Fiducial features405 may also be processed to include a contrast material so that thefeatures 405 may be better viewed under the imaging modality. Forexample, a barium material may be placed in fiducial features 405 toenhance visibility under CT or X-ray. Water or gadolinium may be placedin fiducial features 405 to enhance visibility under MRI. Othermaterials and feature types may be used for other modalities. A furtherfeature of fiducial features 405 is that they be configured so that atracked probe may be touched to them so that their position in patientspace may be determined.

The locations of any holes 402, locating features 403, cutting guides404, fiducial features 405, etc. are known relative to one another andto the coordinate system of template 400.

FIG. 5 is an exemplary depiction of a template 500 used to guideinstruments to predefined locations in an organ (in this example, aprostate gland), according to an aspect of the invention. FIG. 5 shows asegmented view of a prostate gland 501 obtained, for example, frompre-procedure images. It may include an area of interest 502 on whichone or more targets 503 have been identified by a radiologist or otherphysician. In an implementation, the one or more targets 503 may beindividual tumors, or locations within the same tumor that a physicianmay wish to treat with the goal of better treating the complete tumor.

In an implementation, template 500 may be manufactured that includes oneor more holes 505 oriented such that instruments passed there-throughapproach the one or more targets 503 along paths 506. In designing thelocations and orientation of holes 505 for template 500, it may benecessary to assume or select a location at which template 500 should beplaced during the procedure. Once this is known, one or more paths 506may be drawn from the one or more targets 503, intersecting template500, thereby specifying the location and orientation of any holes 505that are to be placed in template 500. This may also impact the shape oftemplate 500, since only the designated paths 506 may need to becontained within the template, and regions such as the region to theright of line 507 that do not include any holes or paths may be removedfrom template 500 without affecting its behavior. Contouring template504 in this way may offer advantages by decreasing the weight oftemplate 500 and/or making template 500 more ergonomic, among otheradvantages.

In an implementation, during a procedure, template 500 may first beplaced in the correct relationship (location and position) relative toprostate 501. In order to correctly hit the targets 503, this may occurduring an alignment step. Instruments placed into holes (ortrajectories) 505 may also be inserted to the correct depth along paths506.

In an implementation, template 500 may be aligned to prostate 501through one or more rotations or translated as indicated in 508.Template 500 may, for example, be moved up/down, left/right,forward/back and rotated as a roll, pitch or yaw motion, or anycombination thereof.

FIG. 6 is a schematic representation of a template 600 with aposition-indicating element (or tracker) 602 and one or more fiducialfeatures 604 attached, according to an aspect of the invention. Tracker602 may be permanently affixed to (or integrated into) template 600.Alternatively, tracker 602 may be removable and replaceable in the sameposition on template 600. Further, tracker 602 may be permanentlyaffixed (or releasably coupled) to a frame assembly that surrounds (orencompasses) all or a portion of template 600.

In an implementation, the location and orientation of the origin 603 oftracker 602 may be known with respect to the one or more fiducialfeatures 604, and to template holes 605 through fixed transformations(e.g., “T1” and “T2”). As shown, T1 represents the transformation from afiducial to the origin 603 of tracker 602, and T2 represents thetransformation from one of holes 605 (that will be used for a needle orother instrument) to origin 603. A transformation (like T1 and T2) willexist for each feature on template 600 to relate origin 603 of tracker602 to each feature. As such, the location and orientation of each hole605 in template 600 is thus known relative to tracker 602. Therefore,when tracker 602 is queried by a tracking device (not shown), theposition and orientation of tracker 602 relative to the tracking deviceallows the position and orientation of each of template holes 605 andfiducial features 604 to be derived in “patient space” (relative to thetracking device).

In one implementation, at least three fiducial features 604 may be usedin conjunction with a probe containing a position-indicating element.The probe (not shown) may be temporarily placed into the fiducialfeatures 604 to locate template 600, and therefore the template holes605.

In one implementation, tracker 602 may be absent, and the fiducialfeatures 604 alone may be used to locate template 600, and therefore thetemplate holes 605. In an implementation, the template holes 605themselves may serve as the fiducial features. In an implementation, thefiducial features 604 may be filled with a contrast agent to render themvisible under an imaging modality. Although shown as holes in FIG. 6 ,it should be appreciated that fiducial features 604 may be any holes,lines, grids, cuts, or shapes etc., or any combination thereof

Alternative Template Design

FIG. 7 is an exemplary depiction of a template 700 comprised of twoplates rather than the solid block of material that comprises templates400, 500, and 600 of FIGS. 4-6 , respectively.

As shown, template 700 comprises a first plate 701 and a second plate702 separated by one or more spacers 704 such that the first and secondplates (701, 702) remain at a fixed distance from one another. In animplementation, the one or more spacers 704 may comprise blocks, rods,tubes, or other shapes, or may alternatively comprise a collar or “plateholder” that surrounds plates (701,702) and fixes them at a prescribeddistance from one another. First and second plates (701, 702) maycomprise plates fabricated from one or more of the materials discussedabove with regard to templates 400, 500, and 600.

According to an aspect of the invention, template 700 may comprise oneor more guide element pairs that define instrument trajectories or otherchannels or passages. For example, first plate 701 may have an opening(or hole) 703 a, and second plate 702 may have a designated,corresponding opening (or hole) 703 b. Opening 703 a (in first plate701) may define an entrance for a device (or instrument) 710, whilecorresponding opening 703 b (in second plate 702) defines an exit fordevice (or instrument) 710, such that device 710 can pass through plates(701, 702), and therefore template 700.

For implementations wherein template 700 comprises multiple guideelement pairs (to allow for the passage of multiple devices), eachrespective pair of guide elements may be similarly labelled to assist aphysician (or other individual) in determining which pairs of guideelements (holes) are related. As an example, first plate 701 may includea marking (e.g., “A” or “1”) located near opening 703 a, while secondplate 702 may include the same marking (e.g., “A” or “1”) located nearopening 703 b such that the physician (or other individual) can quicklyand easily determine that openings (703 a, 703 b) comprise acorresponding pair of openings that collectively define the entrance andexit for a given instrument trajectory (or passage or channel).

By constructing template 700 using a pair of plates (rather than from asingle block), template 700 may be lighter, more compact, and fabricatedat a lower cost, using less material, and/or a lower-cost fabricationtechnique (e.g., by using a three-axis drilling machine instead of amore complex five-axis machine).

In one implementation, first plate 701 and second plate 702 may beconstructed, for example, by printing the hole pattern on sheet(s) ofpaper and manually or photographically transferring the holes locationto each plate, and then drilling them. In another implementation, thelocations of the holes may be transmitted to another location where theplates may be fabricated by a specialized shop or piece of equipment,with the finished plates later sent to the physician performing theprocedure.

In an implementation, the one or more spacers 704 may not be of equallength or diameter (unlike as shown in FIG. 7 ). They may also not besymmetrically placed (unlike as shown in FIG. 7 ).

Other possible plate configurations exist including, for example,partial plates, more than two layered full or partial plates, non-flatplates, etc.

In some instances, a respective pair of guide elements (holes) defininga trajectory (or passage or channel) may be oriented parallel to oneanother such that a given instrument inserted through the holes isperpendicular to the plates. In other words, opening (or hole) 703 a onfirst plate 701 may be aligned with opening (or hole) 703 b on secondplate 701 such that a longitudinal axis of an instrument (e.g., device710) inserted through the holes (703 a, 703 b) is perpendicular toplates (701, 702).

Additionally or alternatively, template 700 may include a respectivepair of guide elements (holes) defining a trajectory (or passage orchannel) that is angled such that a given instrument inserted throughthe holes is not perpendicular to plates (701, 702), but rather extendsthrough template 700 at an angle. In these instances, the openings (703a, 703 b) in plates (701, 702) may be oblong in shape such that thatcylindrical instruments or needles (that are not intended to passthrough template 700 perpendicularly to the plates) are permitted freepassage through plates (701, 702), and therefore through template 700.This is illustrated in the magnified view shown in FIG. 8 , whereopening 703 a of first plate 701 is oblong to allow cylindrical device710 to pass there-through. Characteristics of oblong opening 703 a(e.g., size) may be calculated depending on the angle of the instrument(e.g., device 710) intersecting the plane of first plate 701. Otherinstrument shapes may also be easily accommodated in this manner bycreating hole 703 a (and corresponding hole 703 b) in the correct sizeand/or shape. “Oblong” may be used interchangeably herein with“elliptical,” “ellipsoidal,” “oval-shaped,” “egg-shaped,” or withanother similar descriptor. Further, an “oblong opening” may simply bereferred to as an oblong.

Although plates (701, 702) have been described as comprising planarstructures, they may comprise curved or contoured structures.

Further, although template 700 comprises a pair of plates rather thanbeing formed from a single block, it should be recognized that thevarious components of templates 400, 500, and 600 (of FIGS. 4-6 ,respectively) described in detail above (e.g., guide elements, locatingfeatures, cutting guides, fiducial features, a position-indicatingelement (or tracker), etc.) may also be used with template 700.

Further, although not illustrated in FIG. 7 , in one implementation,plates (701, 702), one or more spacers 704, and/or other components oftemplate 700 may be secured in place a frame assembly or plate holderthat surrounds (or encompasses) all or a portion of template 700.

Use of Template in a Guided Interventional Procedure

FIG. 9 is an exemplary depiction of a template 900 used in a guidedinterventional procedure (in this case, a needle procedure), accordingto an aspect of the invention. In particular, FIG. 9 depicts a patientlying on an operating table 903 undergoing a procedure. The patient isshown in a lithotomy position with feet resting in stirrups 901 with thepatient's perineum 902 positioned near the front of operating table 903.A position sensor 904 (such as, for example, an electromagnetic fieldgenerator or optical camera array) is positioned near the patient. Acoordinate system 905 is associated with position sensor 904. In thisexemplary, and non-limiting implementation, a TRUS probe 906 is placedin the patient's rectum 907 to assist in visualizing the prostate. TRUSprobe 906 may incorporate a removable or permanent position indicatingelement 908 so that the location and orientation of the probe's scanplane is known assuming a calibration as indicated previously has beenperformed.

In this example, a Foley catheter 909 may be inserted into the urethra910. At the distal end of catheter 909, a balloon 911 may be inflated tosecure the catheter at the mouth of the bladder 912. On or in catheter909, a position indicating element 913 may be positioned in the vicinityof the prostate gland 914. Wire(s) 915 from position indicating element913 may be connected to the position sensor 904. The lumen 916 ofcatheter 909 may be used to drain urine from the bladder.

During a guided interventional procedure, a physician (depicted here bygloved hand 917) may use one or more instruments 918 that may optionallyinclude a position indicating element to assist in positioninginstrument 918 in a specific location in prostate 914 by directlypiercing the perineum 902. In an implementation, instrument 918 maycomprise a biopsy needle, hollow cannula, therapy needle such as alaser, or other device. In an implementation, instrument 918 maycomprise a standard instrument that may or may not include a positionindicating element.

According to an aspect of the invention, template 900 may be positionedat a predetermined distance and/or angle from perineum 902. A positionindicating element 921 (similar to position-indicating element ortracker 602 of FIG. 6 ) may be fixed to template 900 such that it isable to track the location and orientation of template 900 with respectto frame of reference 905. In one implementation, if template 900 cannotbe placed in the correct location due to interference with the patientand/or equipment, another template (if available) that was created forplacement in a different assumed location may be utilized. One or moreinstruments 918 may be inserted through one or more holes of template900 to a predetermined depth and into prostate 914, according to apre-procedure plan.

In an implementation, TRUS probe 906 (or other ultrasound probe) may beaffixed to a support mechanism 922. Support mechanism 922 may comprise aBiojet (D&K Technologies GmbH, Barum Germany) or the Multi-purposeWorkstation LP (Civco Inc., Coralville IA) that may include motorsand/or encoders to help position TRUS probe 906 in the patient.

In an implementation, support mechanism 922 may also hold template 900(or a frame assembly that surrounds (or encompasses) all or a portion oftemplate 900. In an implementation, template 900 may be movedindependently from TRUS probe 906. Encoders on support mechanism 922 mayreport the relative location of the template 900. The position andorientation of TRUS probe 906 may be tracked using encoders on supportmechanism 922. In these instances, it may not be necessary to includeposition indicating elements (e.g., such as TRUS probe positionindicating element 908 and template position indicating element 921). Insuch instances, position sensor 904 may be optional unless anotherposition indicating element (e.g., such as catheter position indicatingelement 913) is used.

In one implementation, template 900 may be moved into position usingdials or other controls on support mechanism 922. In an implementation,template 900 may be moved into position in an automated manner using arobotic mechanism attached to support mechanism 922. In animplementation, TRUS probe 906 may be moved in a similar way.

In one implementation, perineum 902 (or another entry point) may becovered with a sterile single or multilayered membrane 990 that maycomprise one or more layers of silicone, latex rubber, thermoplasticelastomer, polyvinylchloride, or other elastomeric material compositedwith an adhesive film. The use of membranes will be described in greaterdetail below with reference to FIGS. 17 & 18 .

It should be appreciated that template 900 may comprise a pair of plates(e.g., such as template 700), or may be formed from a single block(e.g., such as templates 400, 500, and 600 of FIGS. 4-6 , respectively).

Template Hole Variations

It may occasionally be necessary to sample in a region around an actualtarget point to account for system error, registration errors, organmovement, position sensor error, target selection error, needledeflection error, or other issues that may render needle targets notexactly correct. Further, a target may be large or poorly defined, andit may be desirable to sample an area around the focus of a target.

FIG. 10 depicts a situation where it may be desirable to sample multiplelocations 1003 in the vicinity of a target 1002 within an organ 1001.Accordingly, in one implementation, one or more guide elements (e.g.,holes) 1004 in one or more of the plates (1005, 1005 b) comprisingtemplate 1000 may be manufactured as a cluster of holes (e.g., 1006,1007), a cross-shaped hole 1008, a triangular-shaped hole 1009, anenlarged hole 1010, or any other grouping of holes, or enlarged shape,or shape with different cross-sections, such that an instrument (e.g.,needle) 1012 can systematically take multiple different trajectories,one (non-limiting) example of which is indicated as 1011. This enablesmultiple samples to be taken near the same location. One or both ofplates (1005 a, 1005 b) may be modified in this way. In the case of amodification in only one of the plates (e.g., 1005 b), the hole in thesecond plate (e.g., 1005 a) may need to be enlarged or otherwisemodified to accommodate the larger range in trajectories. Multipledepths may also be specified.

In those implementations wherein a block template is used (e.g., such astemplates 400, 500, and 600 of FIGS. 4-6 , respectively), cavities maybe fabricated within the block (using for example rapid prototyping ormilling operations) that permit oversampling in a region as describedabove through creation of an appropriately shaped cavity, for example aconical shape with the cone base positioned at the entry point of theinstrument and the cone tip at the exit of the instrument. The cavitiesin the block may be also be comprised of curved or other shaped pathwayswhich may be advantageous in obtaining a beneficial trajectory of aflexible instrument to the target.

Deployable Restraining Device(s)

In some instances, an organ undergoing therapy or biopsy (or anotherprocedure) may move during the procedure. In such instances, it may beadvantageous to either restrict the motion of the organ, or track itsmotion in order to compensate for its motion. Accordingly, in animplementation designed to track and/or restrict the motion of theorgan, one or more restraining devices may be employed to “pin” (orotherwise secure) an organ in place by using devices such as needles toaffix it. The one or more restraining devices may be removable andrepositionable, and may be designed to engage the tissue or organ (e.g.,such as the breast or prostate) through a hook, suture, balloon, orcatch and restrict its motion by anchoring it to another type of tissuesuch as skin or bone, or to the externally placed device such as atemplate. In an implementation, devices such as a Hawkins I or HawkinsII or Homer needles (Argon Medical Devices, Plano TX) among others, maybe employed. A Foley catheter may also be employed.

FIGS. 11A-11C are exemplary depictions of a deployable restrainingdevice (e.g., a hook needle) that can restrain tissue and also serve totrack its motion, according to an aspect of the invention. While FIGS.11A-11C depict a single restraining device (for ease of illustration),it should be appreciated that multiple restraining devices may be usedsimultaneously.

As shown in FIG. 11A, a tissue 1101 is penetrated by a cannula 1102. Thecannula may pass through a template 1100, and a tissue layer 1104 (e.g.,such as skin).

As shown in FIG. 11B, a needle 1105, is then passed into cannula 1102.Needle 1105 may have a releasable barb or, as illustrated here, may bepre-formed using a shape memory alloy (SMA) or super-elastic material(e.g., such as nitinol) so that it achieves a hook shape when notconstrained by cannula 1102. In FIG. 11B, needle 1105 is shown in its“natural,” unconstrained state. When introduced into cannula 1102,needle 1105 temporarily straightens.

As shown in FIG. 11C, needle 1105 is advanced through cannula 1102 andre-establishes its natural hook shape as it is deployed, securing it inthe tissue. The hub 1112 of needle 1105 and the hub 1113 of cannula 1102may be connected using for example a Luer lock forming a cannula/needleassembly 1114. To restrain the tissue, a locking device 1107 may be usedto engage a tissue layer (e.g., such as the skin surface 1104 or bone).If the cannula/needle assembly 1114 is then fastened to the lockingdevice 1107, the tissue secured by the hook is restricted from movingrelative to the tissue used to secure it (e.g., tissue 1104).

In another implementation, a locking device is placed against template1100 as illustrated by numeral 1108 instead of 1107.

In either case, the locking device 1107 or 1108 may function by grippingtightly to the needle or cannula and simultaneously pressing againsttemplate 1100 or tissue layer 1104. This effectively immobilizes tissue1101 secured by needle 1105. In an implementation, locking device 1107or 1108 may be a releasable collet, clip or other clamp that may betightened on needle 1105 or cannula 1102. The combination of needle1105, cannula 1102 and locking device 1107 may be collectively referredto as a “restraining device,” (numeral 1115 in FIG. 11C).

In an implementation designed to track the motion of the tissue or organfor dynamic referencing or gating, one or more such restraining devicesmay be constructed that incorporate one or more position indicatingelements that may be used to monitor the position of the object intowhich it is inserted. Such a device is described, for example, in U.S.Pat. Nos. 6,785,571 and 7,840,251 to Glossop, each of which is herebyincorporated by reference herein in its entirety. An exemplaryposition-indicating element 1110 is illustrated in FIG. 11B. Here theposition sensor is connected to position-indicating element 1110 usingcable 1111.

In one implementation, the one or more restraining devices 1115 mayincorporate a temperature sensor placed within it, so that thetemperature of the tissue or organ that it contacts may be measured.This may be particularly important in determining the effect of athermal or cryogenic ablation process such as cryoablation,radiofrequency ablation, laser assisted ablation, microwave ablationetc.

Other types of sensors may also be used together with the restrainingdevice 1115 to measure other properties of tissue, or progress ofprocesses used to treat the tissue. These may include, withoutlimitation, optical sensors, radiation sensors, pressure sensors,acoustic sensors, chemical sensors, electrical sensors, etc. Therapydevices may also be incorporated within the one or more restrainingdevices 1115 to deliver heat, drugs, etc.

In an implementation, the one or more restraining devices 1115 mayincorporate a plurality of sensor types such as, for example atemperature sensor and/or a position sensor. In an implementation, theone or more restraining devices may incorporate a plurality of hooks tobetter restrain the tissue and any sensors.

FIG. 12 is an exemplary depiction of a catheter including aposition-indicating element that can be used to track motion of a tissueor organ, according to an aspect of the invention.

In an implementation, a catheter 1201 (e.g., a Foley catheter) may bepositioned in a patient and inflated in order to immobilize a tissue ororgan (e.g., the prostate) as indicated in FIG. 12 . The inflationballoon 1205 normally used to retain the catheter may also serve toimmobilize the prostate. A dual balloon Foley catheter such as a Colemanor Lerman catheter (C.R. Bard, Inc., Murray Hill, NJ) may also be used(not shown). One balloon may be inflated in the urethra to restrain it,while the second may be inflated at the bladder neck.

In an implementation designed to track the motion of the tissue or organfor dynamic referencing or gating, the Foley catheter above may beequipped with a position-indicating element such as that described inU.S. Pat. No. 8,948,845 to Glossop et al. which is hereby incorporatedby reference herein in its entirety. This would enable the catheter tobe used in order to track the location of the prostate during theprocedure. In an implementation, the Foley catheter above may serve thedual function of immobilizing the tissue and tracking any motion thatoccurs.

In the implementation illustrated in FIG. 12 , catheter 1201 may includea position-indicating element 1202. In an implementation shown in theinset of FIG. 12 , a plurality of position indicating elements 1202 a,1202 b, 1202 c, and 1202 d may be included within catheter 1201.Position indicating elements 1202 may be located using a tracking devicefor purposes of dynamic referencing and registration as detailed below.In an implementation, the position-indicating elements may be attachedwithin one of the existing lumens of the catheter, such as a ballooninflation lumen, the drainage lumen, or in an irrigation lumen of athree lumen catheter, or in a special dedicated lumen, here indicated as1203.

In a similar manner, electrical cables 1204 may be threaded through alumen. The position-indicating elements may be contained in a tube thatis inserted into one or more of the lumens of catheter after thecatheter has been placed rather than being integrated in the catheter.In an implementation, a catheter locking device 1206 may be present tohelp constrain the catheter and balloon from moving.

In an implementation, a catheter 1201 such as the one depicted in theinset of FIG. 12 that includes multiple position indicating elements(1202 a, 1202 b, 1202 c, 1202 d) may be used to perform apatient-to-image registration. This can be done if a pre-procedure imageset (such as an MRI) of the patient into which the catheter is laterinserted is available, and details of the construction and placement ofeach of the multiple position indicating elements is known.

In an implementation, the positions in which each position-indicatingelement (1202 a, 1202 b, 1202 c and 1202 d) has been secured in catheter1201 is known relative to balloon 1205 of catheter 1201 at the time ofmanufacture. When catheter 1201 is inserted into the patient and balloon1205 is inflated, the approximate location of each position indicatingelement within the pre-procedure images of the prostate may be deducedbecause:

-   -   (a) The linear displacement of each position indicating element        relative to the bladder neck is known since balloon 1205 is        lodged against it; and    -   (b) The path of the urethra and thus catheter 1201 through the        prostate is known from a pre-procedure MRI scan.

Therefore, if the path of the urethra is determined from scans takenprior to the operation, the position and orientation of the positionindicating elements may be deduced in image space. The locations andorientations of the position indicating elements may be determined bythe position sensor in patient space. This allows a registration to beperformed relating the position indicating elements positions (patientspace) and orientations and the assumed positions from the pre-procedurescans (image space). This registration may be used to target any devicethat contains a position indicating element.

In a more general form, a catheter including a plurality of positionindicating elements (either built-in, or temporarily placed) may be usedto register any lumen that it is placed in as long as:

-   -   (a) Locations of the plurality of position-indicating elements        in the catheter is known;    -   (b) The catheter is placed at a known location in the patient        anatomy; and    -   (c) The path of the catheter is constrained to follow a lumen        visible on the images.

Since the location of the position-indicating elements in the images canbe inferred by the known geometry of the lumen and the known location ofthe origin of the catheter and the known location of theposition-indicating elements within the catheter, they may be used toperform the registration. In an implementation, this method may be usedto register anatomy with lumens such as the lungs, and vascular organs,for example.

Exemplary Flowchart

FIG. 13 is an exemplary flowchart 1300 of processing operations (orsteps) for creating and using a template in a guided interventionalprocedure (e.g., placing a needle or other instrument for performing abiopsy, placing fiducials, or performing a therapeutic (or other)procedure), according to an aspect of the invention. Flowchart 1300 isdivided into two sections, comprising a set of pre-procedural steps, anda set of intra-procedural steps.

The described steps may be accomplished using some or all of the systemcomponents described in detail above and, in some implementations,various steps may be performed in different sequences and various stepsmay be omitted. Additional steps may be performed along with some or allof the steps shown in the depicted flow diagram. One or more steps maybe performed simultaneously. Accordingly, the steps as illustrated (anddescribed in greater detail below) are exemplary by nature and, as such,should not be viewed as limiting.

Pre-Procedural Steps

In a step 1301, an imaging modality such as an X-ray, MRI, CT,ultrasound, tomosynthesis, PET, or other imaging modality may be used toobtain one or more two-dimensional (2D) or volumetric images of apatient's anatomy. This may take the form of contrast-enhanced,multi-parametric, or other variation of the scan or scans. The imagesmay be formed into a three-dimensional (3D) image stack which showsdetails of the anatomy from many slices. Fiducials, if used, should beapplied prior to the scan, and the scan should encompass both thefiducials and the anatomy.

In a step 1302, the scan(s) may be reviewed by a radiologist or otherspecialist, or processed by a Computer Aided Diagnosis (CAD) program, orother software (e.g., control application 307). One or more targets maybe annotated along with critical structures (e.g., the urethra, nerves,vessels, bones such as ribs, etc.). This information (target(s) andstructure(s) or other information) may be annotated on the images, as aseparate list of points and volumes, or stored in a database (or memory)along with other information, for example. Targets may also include aselection of targets designed to represent an orderly and representativesampling through an organ as might be desired during a sextant-style orsaturation-style biopsy of, for example, the prostate which aims tosample from throughout the gland. Other targets may cluster more denselyaround certain structures deemed to be important for either therapy orbiopsy such as, for example, local dose boosting around a suspectedtumor whilst placing radioactive brachytherapy seeds. Yet anothernon-limiting example is an optimized treatment pattern for a large tumorto be treated by multiple successive or simultaneous thermal orcryoablations.

In a step 1303, the scan(s) may optionally be segmented to outline theorgan of interest and/or regions of interest (ROI). This information maybe annotated on the images, as a separate list of points and volumes, orstored in a computer database (or memory) along with other information,for example. This information may be used for registration among otherthings. In some implementations, step 1303 may be combined with step1302.

In a step 1304, a mathematical model of a template (or “virtualtemplate”) may be generated (e.g., using control application 307) fromthe information gathered in steps 1302 and 1303. At the time ofintervention, the template may first be assumed to be positioned andoriented in one or more locations. These assumed positions andorientations may then be replicated during the intervention procedure byplacing the template in the one or more locations during the procedure.Paths to targets may then be generated from the target eitherautomatically or manually such that they pass through the template.Multiple approaches that pass through the template may be possible, suchthat those that avoid critical structures (e.g, annotated during step1302) are preferentially selected. Paths may also be selected so theyare not too close together, or are otherwise more convenient for theactual procedure. The intersection of these paths with the template maybe calculated, and the path through the template may be generated. Thismay continue for all of the targets selected in steps 1302 and 1303, orfor any additional targets. Details of this planning procedure are setforth in greater detail below in reference to FIGS. 14A-14D.

In one implementation, multiple separate templates may be fabricated.Each template may, for example, be designed to be placed in a differentlocation from the other in case the selected positioning of the initialtemplate is not easily accessible for the particular patient setupencountered during the actual medical procedure. In such an instance, adifferent template may be selected that would be placed in a slightlydifferent location that allows the procedure to be more easilyperformed. The multiple templates if used may also be placed in the sameposition in the case of extremely complex plans for example, in which asubset of treatment holes or paths would be drilled into each template.In this case multiple templates may be manufactured and so mathematicalmodels of the various templates should be generated.

In a step 1305, the template(s) may be fabricated based on themathematical model(s) generated in step 1304. The fabrication step mayuse the information generated in step 1304 to produce a templateconsisting of a single block (e.g., templates 400, 500, or 600) or twoor more plates (e.g., template 700) that may be later connected using aspacer. Fabrication may occur using a computer numerical control (CNC)milling machine in which an automating machine is programmed to drilltemplate holes at the correct location and orientation into one or moretemplate “blanks” that does not contain any holes. In an implementation,fabrication may take place using an additive manufacturing process suchas 3D printing. In an implementation, multiple templates may befabricated for placement at different locations during the procedure incase a block is not easily positioned in the location initiallyselected. As previously noted, the template may be manufactured from anyacceptable material that may be easily machined and sterilized and iscompatible with the procedure. For example, the template may bemanufactured from a biocompatible material that may be sterilizedwithout causing a dimensional change to the template. In animplementation, fabrication may occur at a specialized manufacturingfacility, and the finished parts may be delivered to the physician forthe procedure. In an implementation, fabrication may could occur withinthe hospital. Additional details on the fabrication of the template arediscussed below in reference to FIG. 15 .

Templates may be tested for accuracy by, for example, simulating theintervention to ensure that instrument(s) will pass through the templateto the correct location(s). Various forms of simulation are possibleincluding, for example, optically shining a laser or light through theholes, or passing an instrument for example in conjunction with a tissuesurrogate or “phantom” manufactured using a rapid prototyping methodfrom a pre-operative scan so as to simulate the actual medicalintervention.

In a step 1306, the template(s) created in step 1305 may be sterilizedand packaged using a suitable microbial barrier material such as aTyvek® peel-pouch. The template(s) may then be transported to aprocedure room when required for the interventional portion of theprocedure.

Intra-Procedural Steps

During a procedure, in a step 1307, a patient may be optionally equippedwith a dynamic reference such as a tracked Foley catheter or trackingneedles, or other dynamic reference device or system. Restrainingdevices or needles may also be placed in the patient to help fix theorgan undergoing intervention, as discussed in detail above withreference to FIGS. 11A-11C.

In a step 1308, a TRUS or ultrasound (or other imaging modality) may beintroduced and the prostate or other organ may be imaged. In animplementation, the template may be attached to a support mechanism thatallows it to be positioned through fine adjustments of positioning knobsor dials (or other controls), or through a robotic positioning system.

In an implementation, the imaging probe may be hand-held. The imagingprobe (e.g., US probe) may have multiple scan planes such as the BK 8188triplane probe (BK Medical, Peabody MA). In an implementation, the probemay have a position indicating element attached thereto such that thelocation of the scan plane(s) is known at all times. The probe may becalibrated so that knowledge of the scan probe location and image on thescan can determine the location in patient and image space of any pointin the scan image.

In a step 1309, the anatomy may be registered with the pre-procedureimage(s). This may be accomplished using methods that have beendiscussed previously, such as through the use of fiducials, so that thetransformation between “patient space” and “image space” may becalculated.

Additionally, a type of manual registration may be performed by movingthe ultrasound probe until the image from the ultrasound best matchesthat of the pre-procedure image. Once that is achieved, the images maybe “locked” (e.g., when the probe is moved, the pre-procedure image isreformatted along the same plane as the ultrasound). Other methodsinvolve identification of items on both the ultrasound and on thepre-procedure scan, finding the best fit of an ultrasound sweep of theprostate, etc. Other methods of registration are possible such as theFoley catheter method previously discussed.

In a step 1310, the template may be aligned to the preplanned position.This location may, for example, be set by monitoring the positionindicating element on the template (if used), or by moving themechanical positioning system until the template is in the position andorientation that was determined in step 1304. In step 1304, thepreplanned position of the template was determined in image space. Asthe transformation between image space to patient space is known fromthe registration in step 1309, the preplanned position of the templatecan be transformed into patient space. Thus, the position that thetemplate should be placed in is known in patient space and it may bealigned to this position. Methods for aligning the template aredescribed in additional below in reference to FIG. 16 .

In one implementation, a custom mold, vacuum cushion, or otherpositioning system may be used at the time of the scan in step 1301,allowing repeatable patient positioning at the time of the interventionthereby obviating the need for tracking the template.

In a step 1311, an instrument (e.g., a needle) may be introduced intohole(s) in the template. The instrument location may be used to verifythat the template is aligned correctly. In an implementation, thelocation at which the needle would appear if correctly introduced in thetemplate may be predicted and displayed as a graphic overlay on the liveultrasound image. If the actual image of the needle and the graphicoverlay of the predicted needle location match up, then the system isaligned and the remaining needles may be introduced. If not, thetemplate may be realigned (re-registered), and checked again.

Accuracy may also be verified using targets or “check fiducials” placedon the skin. These may be annotated as “targets,” and templated pathsmay be generated. Needles placed in the paths would touch the checkfiducials in cases where the system was performing correctly. Trackedneedles may also be used and their locations compared to the plannedpath. Other means of verifying the correctness of the template andpositioning of the template are also possible.

When inserting a device such as a needle, the depth of insertion isknown from step 1304. In an implementation, the system may report theinsertion depth to the physician. This information may be communicatedto the physician via a display, so that the physician may mark or placea “needle stop” on the needle prior to insertion. In an implementation,the physician may observe the needle location on the ultrasound toensure it is at the correct depth. In an implementation, if a trackedneedle is used, the system may report the depth.

In a step 1312, the procedure may continue with instrument(s) beingintroduced into the hole(s) set in the template to the prescribed depth,and the procedures may be performed until complete. In animplementation, multiple instruments may be inserted simultaneously, orone instrument may be inserted at a time.

In one implementation, the template may be preserved for subsequentprocedures at a later date (e.g., to re-biopsy locations that have beenbiopsied or treated, to re-treat partially treated areas, to treat areasthat have been further verified under another imaging modality, etc.).

Positioning a Template and Generating Paths

FIGS. 14A-14D are exemplary depictions of method steps for positioning atemplate, and for generating paths through the template, according to anaspect of the invention. The following description elaborates onplanning step 1304 described above with reference to FIG. 13 . Thedescribed steps may be accomplished using some or all of the systemcomponents described in detail above and, in some implementations,various steps may be performed in different sequences and various stepsmay be omitted. Additional steps may be performed along with some or allof the steps shown in the depicted flow diagram. One or more steps maybe performed simultaneously. In general, these steps may be performed ona computer device (e.g., computer device 301) that is capable ofdisplaying and manipulating graphical objects. Accordingly, the steps asillustrated (and described in greater detail below) are exemplary bynature and, as such, should not be viewed as limiting.

In the example set forth in FIG. 14A, a tissue (e.g., prostate) 1401 isimaged as previously described (e.g., as one or more of MR, CT,multi-parametric, MRI, etc.). The following steps may be used to planthe position and orientation of a template, and generate one or morepaths through it.

(1) First, one or more targets 1402 (e.g., lesions) may be identified onthe scan.

(2) Next, a representation of the plates 1405 of a template (only afront plate is shown in FIG. 14A) is generated on the computer display(e.g., display device 310). These plate representations may be rotatedor moved in the display.

(3) A “virtual probe” 1408 may be created on the display that isperpendicular to the front plate at its center (although any convenientlocation or orientation may be selected). In an implementation, thelength of virtual probe 1408 is set to a distance of “d” cm (or otherunit of measure) from the origin of the plate, and made perpendicular tothe plate. The length of virtual probe 1408 may typically fall in therange of 1-2 cm., although any length may be used. The virtual proberemains perpendicular to the plates for the remainder of the operations.

(4) Next, a point may be selected on, for example, a graphicrepresentation of the surface of the skin 1404 as a “pivot point” 1403.The pivot point may roughly represent the location at the center of theoperative field.

(5) Plates 1405 (which may be locked together) and virtual probe 1408may then be translated such that the tip of virtual probe 1408 islocated on pivot point 1403. The orientation of plates 405 is preservedas set in step (2), but any applied translation is lost. In animplementation, the orientation relative to coordinate system 1406selected prior to selection of pivot point 1403 is preserved.

(6) At this point, the plates 1405 may be “locked” to the pivot point,and any rotation occurs around pivot point 1403 as if the plates 1405were pivoting on the tip of virtual probe 1408. As shown in FIG. 14B,for example, the rotation of plate 1405 from position 1405 a to position1405 b is shown to occur about pivot point 1403.

(7) If pivot point 1403 is moved, as shown in FIG. 14C, the plates andvirtual probe 1408 may be moved, but not re-oriented. This is shown inFIG. 14C as the plates being translated from position 1405 c to 1405 d,and concomitant translation of the pivot point from position 1403 to1403 a. Similarly, if the plates are translated, the virtual probe andpivot point are translated in the same manner.

(8) If the plates are to be translated, as shown in FIG. 14C, the newpivot point 1403 a is established, however the distance “d” remains thesame, and subsequent rotations will occur around new pivot point 1403 a.

(9) Next, as shown in FIG. 14D, various trajectories 1410 may beestablished through the plates intersecting targets 1402.

(10) The orientation of the plates, the paths of the varioustrajectories 1410, the location of the pivot point 1403, and theposition of the holes to be drilled 1411 in plates 1405 to obtain thetrajectories may be recorded.

Although it has been assumed that the virtual probe is perpendicular tothe plates, it is understood that any known fixed angle may be used.Although the foregoing method is described with reference to plates, itis understood that the same method may be used for the block form of thetemplate (e.g., such as templates 400, 500, and 600 of FIGS. 4-6 ,respectively).

Template Fabrication

FIG. 15 is an exemplary depiction of a template 1500 with an extensionpost 1506 that may assist in positioning of template 1500 in a plannedposition and orientation, according to an aspect of the invention. Thefollowing description elaborates on fabrication step 1305 describedabove with reference to FIG. 13 . The described steps may beaccomplished using some or all of the system components described indetail above and, in some implementations, various steps may beperformed in different sequences and various steps may be omitted.Additional steps may be performed along with some or all of the stepsshown in the depicted flow diagram. One or more steps may be performedsimultaneously. Accordingly, the steps as illustrated (and described ingreater detail below) are exemplary by nature and, as such, should notbe viewed as limiting

Prior to performing a guided interventional procedure, a template 1500comprising a pair of plates may be fabricated according to determinedspecifications, and aligned as follows.

(1) First, one or more holes (or oblongs) may be drilled through theplates (comprising template 1500) at the locations representing theintersection of the target trajectories through the plates as has beendescribed earlier. Additional holes may be drilled to accommodatethermocouples or other sensors, or for devices to assist in fixating theorgan. The drilled plates (the back plate 1507 is shown here) may thenbe attached to a plate assembly or frame 1505 as shown in FIG. 15 . Aposition-indicating element (or tracker) 1504 may be rigidly affixed (orreleasably coupled) to plate assembly or frame 1505. As shown,trajectory holes are marked as 1501, while additional holes are markedas 1502 and 1503. The location of holes 1501, 1502, and 1503 areexemplary and may, of course, differ for different templates.

(2) An extension post 1506 (having a length “d”) may be affixed to thecenter of the front plate, as determined during the planning phase.

(3) During the interventional procedure, plate assembly or frame 1505may be moved to the position that was determined during the planningphase by moving plate assembly or frame 1505 while taking measurementsof the tracker location and orientation. Plate assembly or frame 1505may be moved via a support mechanism (described above) that is coupledto plate assembly or frame 1505. When the difference between the trackerposition and orientation and the planned position and orientation isclose to zero, the assembly may be locked in that location and theprocedure performed.

Although it has been assumed that the extension post 1506 isperpendicular to the plates, it is understood that any known fixed anglemay be used as long as it conforms to that used during the planningphase. Although the foregoing method is described with reference toplates, it is understood that the same method may be used for the blockform of the template.

Template Alignment

FIGS. 16A-16F depict exemplary user interfaces for aligning a templateto a preplanned position and orientation, according to an aspect of theinvention. The following description elaborates on alignment step 1310described above with reference to FIG. 13 . Typically these images wouldbe displayed on a display (graphical interface) associated with acomputer device (e.g., computer device 301) to assist a physician inaligning the template to the planned position.

According to an aspect of the invention, various user interfaces may beused to perform alignment of the template, including a “circlealignment” (in which a pair of computer-generated circles is made toline up on a cross-hair) by monitoring the position and orientation ofthe template using the position sensor, and moving the circles of thegraphical interface accordingly. This is a user interface that may berapidly and easily used to align the plates either manually or with amechanical alignment system. In addition, robotic methods may be used toalign the plates.

A “circle alignment” graphical aid to help position the plates is shownin FIGS. 16A-16F. In FIG. 16A, a fixed crosshair 1601 is shown alongwith a first circle 1602 and second circle 1603 adjacent to crosshair1601. As the template's extension post (1506 in FIG. 15 ) is translatedby moving the template at a fixed orientation, first circle 1602 (the“translation circle”) moves in the plane of crosshair 1601 as indicatedin FIG. 16B. When the position of the extension post on the skinachieves the planned pivot point, first circle 1602 will be located inthe center of crosshair 1601 as shown in FIG. 16B. Because of theextension post on the plate assembly, correct positioning of translationcircle 1602 is achieved by adjusting the template location in 2directions on the skin surface (left, right, and up and down), as athird direction (moving the template closer and farther from the skin)is constrained (the post must lie on the skin surface), hence twodirections on the crosshair is sufficient to determine the location ofthe pivot point.

Second circle 1603 (the “orientation indication circle”), may then bemoved by orienting the template by pivoting it about the pivot point onthe skin surface without translating it. This action is translated by acomputer program (e.g., control application 307) into a movement ofsecond circle 1603 as shown in FIGS. 16C and 16D. In FIG. 16D,orientation in two axes and translation in three axes are aligned.

The axial rotation (“roll”) of the template is the final degree offreedom, and may be achieved by maintaining the position and orientationof the template while rotating it around the axis of the extension post.To indicate this, an implementation shown in FIG. 16E and FIG. 16F usesthe diameter of the second (orientation) circle 1603 to indicate theroll alignment. Second circle 1603 is made to expand or shrink so thatwhen it is in the correct location it is rendered as a small point asshown in FIG. 16F. Other methods may be used to indicate the rollalignment such as a bar graph, color change or other graphicalindication.

Once the five unconstrained parameters are aligned (the plates axialrotation, yaw, pitch, and location on the skin surface), the template isaligned and the procedure may commence. The sixth parameter, thedistance from the plate to the entry point, is constrained by theextension post.

In one alternative implementation, and as addressed in greater detailbelow, the plates comprising the template may be manufactured during theprocedure, rather than before the procedure. In such an implementation,the template plates may not be attached to a plate holder. The plateholder may be placed into a convenient position that has not beenprecisely planned a priori. The location and orientation of the plateholder may then be recorded using an attached tracking device and fixedin that position. If the organ of interest is registered using a methodsuch as is known in the art (such as that, for example, disclosed inU.S. patent application Ser. No. 11/508,835 to Glossop which is herebyincorporated by reference herein in its entirety), it is possible todetermine the locations of targets relative to the plate holder, and theholes in the plates may be drilled. The drilled plates may then beinserted or attached to the fixated plate holder and the procedure ofinserting needles or other instruments through the holes may proceed.

In one implementation, a probe such as a tracked needle probe may beemployed to verify that a plate has been created correctly, and that theoutcome will be the desired one. A probe, such as that described in U.S.Pat. Nos. 6,785,571 and 7,840,251 to Glossop (each of which is herebyincorporated by reference herein in its entirety), may be inserted intothe plate assembly, and the progress followed on a computer display. Inaddition, a tracked or untracked ultrasound may be used to verifypositioning of any needle inserted into the grid.

Although the system device and method described herein are described inmany places in reference to prostate therapy and biopsy, it isunderstood that the identical or substantially similar techniques may beapplied to other organs or targets in the body with only minormodifications. For example, it may be applied to liver therapy or breasttreatment by using a different support mechanism and differentultrasound transducer. It may be applied also to organs such as lungs,bones, kidney, brain, spine etc. Other minor changes such as the form ofthe dynamic reference device may also be required so that instead of aFoley catheter, a device such as that described in U.S. Pat. No.7,751,868 to Glossop (which is hereby incorporated by reference hereinin its entirety), may be used.

Membrane

According to an aspect of the invention, during a guided interventionalprocedure, a membrane may be applied to (so as to cover) a skin entrypoint of an instrument (e.g., a needle). For example, as shown in FIG.17 , membrane 1790 may cover the perineum 1702 (or other skin entrypoint).

In one implementation, membrane 1790 may comprise a sterile, singlelayer membrane composited with an adhesive film. In an alternativeimplementation, membrane 1790 may comprise a multilayer membranecomposited with an adhesive film.

Examples of materials that may be used for the sterile, single layermembrane and the multilayer membrane may include, but are not limitedto, silicone, latex rubber, thermoplastic elastomer, polyvinylchloride,or other elastomeric material composited with an adhesive film. Membrane1790 may be releasably adhered to the perineum or other skin entry pointof an instrument so as to be supportive to any instruments passingthrough the membrane. This will assist in maintaining the targeting ofan instrument (e.g., a needle) in place such that it does notappreciably pull out or move if the patient moves, or if the instrumentis subject to incidental contact, for example.

Membrane 1790 may be easily punctured by a sharp object such that aneedle or other instrument may pass through the membrane easily. In thisregard, the self-adhesive membrane would allow free passage of aninstrument though it, but also offer support to the instrument.

In an implementation, the size and shape of membrane 1790 may becustomized to provide easy placement. The membrane may also be fittedwith fiducial markings in the form of points, lines, or grid lines etc.using another material or the material of the membrane that has beenprocessed in some way so that the fiducial markings are rendered visibleon one or more imaging modalities to help localize instrument placement.In an implementation, the fiducial markings may be constructed of abiocompatible and structurally stable material.

In one implementation, membrane 1790 may be used during a guidedinterventional procedure without a template (as shown, for example, inFIG. 17 ). Alternatively, a membrane may be used during a guidedinterventional procedure with a template. FIG. 9 , for instance, depictstemplate 900 and membrane 990.

FIG. 17 depicts a patient lying on an operating table 1703 undergoing aprocedure (in this instance, an image guided transperineal biopsy). Thepatient is shown in a lithotomy position with feet resting in stirrups1701 with the patient's perineum 1702 positioned near the front of theoperating table 1703. A position sensor 1704 (such as, for example, anelectromagnetic field generator or optical camera array) is positionednear the patient. A coordinate system 1705 is associated with positionsensor 1704. In this exemplary, and non-limiting implementation, a TRUSprobe 1706 is placed in the patient's rectum 1707 to assist invisualizing the anatomy. TRUS probe 1706 may incorporate a removable orpermanent position indicating element 1708 so that the location andorientation of the probe's scan plane or planes is known.

In this example, a Foley catheter 1709 may be inserted into the urethra1710. At the distal end of catheter 1709, a balloon 1711 may be inflatedto secure the catheter at the mouth of bladder 1712. On or in catheter1709, a position indicating element 1713 may be positioned in thevicinity of the prostate gland 1714 for the purposes of dynamicallyreferencing the prostate. Wire(s) 1715 from position indicating element1713 may be threaded through a lumen in the catheter and connected toposition sensor 1704. The lumen 1716 of catheter 1709 may be used todrain urine from the bladder.

During a guided interventional procedure, a physician (depicted here bygloved hand 1717) may use one or more instruments 1718 that mayoptionally include a position indicating element to assist inpositioning instrument 1718 in a specific location in prostate 1714 bydirectly piercing the perineum 1702.

The procedure may be performed by first using TRUS probe 1706 toregister the patient's prostate 1714 with the pre-operative scans andsegmented images. Other registration methods may be used. Targetsidentified on the pre-operative images may be transferred to the liveimages from the ultrasound so that they appear as graphic targets on theultrasound view. Instrument (e.g., needle) 1718 may then be directedtoward each of the targets with the assistance of the position feedbackobtained from the position indicating element which may also show theinstrument position relative to the target as a graphic representationof an instrument tip and target.

FIG. 18 depicts a membrane 1890 (that may be affixed to a patient'sskin) to aid in positioning one or more tubes during a procedure beingperformed on an organ 1801 (e.g., a prostate). As shown, target organ1801 contains a suspected tumor 1802 detected on an imaging modality(e.g., such as multiparametric, MRI, or other imaging modality). Tumor1802 may contain a target 1803 that represents the location determinedby a physician during a planning phase for a biopsy, ablation,injection, device placement, or other procedure.

In an implementation, one or more hollow tubes 1804 may be positionedand angulated so that straight devices such as needles 1805 passingthrough the lumens of tubes 1804 and the skin surface 1806 will convergeat the target or targets while avoiding critical structures such aslumen 1807 that could represent the urethra, a blood vessel, a nerve, aduct or other critical structure. In this depiction, dashed lines 1808represent the path that devices would take if placed in tubes 1804.

In an implementation, the one or more tubes 1804 may be equipped with aposition indicating element such as an LED array, or externally wrappedwith a coil 1809. This enables the position indicating element to helplocate the entry point and orientation of the one or more tubes 1804.

In an implementation, the tubes may be positioned by removably placing aneedle containing a sensor (such as that described with reference toFIG. 2 ) which may be used to assist in the placement of the one or moretubes 1804 and then withdrawn. The one or more tubes 1804 may be placedusing a robotic mechanism, a stereotactic mechanism, or other mechanism.In an implementation, the needles may be held in place by a supportmechanism (not pictured).

Fiducial Array

According to an aspect of the invention, and with reference to FIGS.19-21 , it may be desirable to use a template without a positionindicating element and/or position sensor during a medical procedure inone more instances. One non-limiting example of such an instance mayarise when a medical procedure can begin in a scan room, and a patientdoes not move after the scan. Various methods may be used to assist inkeeping the patient stationary from the time of a scan until the time ofan interventional procedure, including the use of restraints, vacuumcushions, custom molds, or other equipment.

FIG. 19 is an exemplary depiction of a fiducial array 1901 used in aguided interventional procedure, according to an aspect of theinvention. In one implementation, fiducial array 1901 may be placed in afield of view 1902 of a scanner (not shown). If a scan is performed withfiducial array 1901 in place and scanned along with a patient 1903,fiducial array 1901 and patient 1903 are imaged simultaneously.

Fiducial array 1901 may comprise a rigid object that is compatible withthe imaging system, and may be comprised of metals, composite materialssuch as graphite-epoxy or plastics, or other materials. Fiducial array1901 may have any shape (e.g., a block, or a curved or contouredstructure). In an implementation wherein fiducial array 1901 comprises acurved or contoured structure, the contours of fiducial array 1901itself may be visible on an image. In one implementation, fiducial array1901 may comprise a template holder (e.g., as illustrated in FIG. 20 anddescribed in detail below).

Fiducial array 1901 may comprise one or more discrete fiducials such as,for example, point fiducials 1904 made from an imageable material suchas: (i) steel or tantalum beads for X-ray or CT images; (ii) wells orbeads containing vitamin E, water or gadolinium in the case of an MRIscanner; (iii) an echogenic material for ultrasound imagers; or (iv) aradioactive material in the case of a gamma camera, PET imager orsimilar device. Various materials are possible depending on the type ofimager used. As such, the foregoing examples should not be viewed aslimiting. It may be desirable that fiducial array 1901 include materialsthat appear of high contrast in images. It may also be desirable to makethe imageable materials in fiducial array 1901 (or fiducial array 1901itself) asymmetric so that automated techniques may be used to segmentthe fiducials unambiguously from the images.

In one implementation, fiducial array 1901 may include one or morepathways 1905 that may be used to house an imageable material. Examplesof imageable materials may include stainless steel wires, or fluidchannels in which materials such as those mentioned above may be placed.Pathways may be internal to the fiducial array or attached externally.

In one implementation, fiducial array 1901 may be coupled to a scanner,the patient or a portion of his/her anatomy, a patient bed (includingbeing embedded therein), or other piece of equipment via a post oradjustable mounting arm 1906. Further, in various implementations,fiducial array 1901 and/or mounting arm 1906 may include one or morefeatures for attaching additional devices thereto in fixed relation tothe fiducial array 1901. As a non-limiting example, FIG. 19 depicts oneor more features 1909 coupled to fiducial array 1901. Non-limitingexamples of features 1901 may include, for instance position sensors,imaging devices such as ultrasound transducers, biopsy devices, therapydevices etc.

As noted above, although in this implementation it may be desirable touse a template without a position indicating element and/or positionsensor, fiducial array 1901 may, in certain implementations include aposition indicating element 1907 that may be tracked by a positionsensor 1908 (in a manner similar to that described elsewhere herein). Acoordinate system 1910 is associated with position sensor 1908. In someimplementations, the scanner may also be tracked by a position sensor,if desired. Once the scan is complete, if position indicating element1908 is absent, then it is desirable not to move fiducial array 1901.

According to an aspect of the invention, fiducial array 1901 may beremoved or augmented following imaging in order to attach a template.According to an implementation, removal of the array is performed insuch a way as to be able to reattach it in the same location.

In FIG. 20 , a template 2000 is shown attached to fiducial array 1901.Template 2000 may comprise a pair of plates (e.g., such as template700), or may be formed from a single block (e.g., such as templates 400,500, and 600 of FIGS. 4-6 , respectively), as described in detail above.Further, template 2000 may comprise one or more holes to enable passageof one or more devices 2003 (e.g., needles or other devices)there-through to converge on one or more targets in an organ of interest2004.

In one implementation, a transformation 2006 (T1) between fiducial array1901 and template 2000 is known or may be calculated from the design oftemplate 2000 and array 1901 enabling the position and orientation oftemplate 2000 to be calculated relative to fiducial array 1901.Therefore, it may be possible to completely remove fiducial array 1901from mounting arm 1906 and attach template 2000, so long as atransformation 206 (T1) between the coordinate system of fiducial array1901 and template 2000 is preserved. The position in image space of thetemplate 2000 is therefore known, and thus relative to the targetanatomy 2004.

In one implementation, template 2000 may be coupled to fiducial array1901 forming an “augmented fiducial array” that is a combined form offiducial array 1901 and template 2000, where the location andorientation of template 2000 is known relative to fiducial array 1901,and thus relative to target anatomy 2004.

In one implementation, as noted above, fiducial array 1901 may comprisea support structure such as, for example, a frame for holding templates.A frame and template, when combined, form a combinational device offiducial array 1901 and template 2000, where the location andorientation of template 2000 is known relative to fiducial array 1901,and thus relative to target anatomy 2004.

In one implementation, a position indicating device may be placed on orin the patient to monitor for motion changes. Dynamic referencing orgating of this kind was discussed herein previously.

FIG. 21 is an exemplary flowchart 2100 of processing operations (orsteps) for using a fiducial array and a template in a guidedinterventional (or other) procedure, according to an aspect of theinvention. The described steps may be accomplished using some or all ofthe system components described in detail above and, in someimplementations, various steps may be performed in different sequencesand various steps may be omitted. Additional steps may be performedalong with some or all of the steps shown in the depicted flow diagram.One or more steps may be performed simultaneously. Accordingly, thesteps as illustrated (and described in greater detail below) areexemplary by nature and, as such, should not be viewed as limiting

In a step 2101, a patient may first be placed on an operating orprocedure table. This method does not require the use of a positionsensor, although use of one may confer advantages in detecting whetherthe patient moves after the scan, or correcting for patient movement. Itmay also allow flexibility in the movement or correction of the positionand orientation of a template after the scan has been performed.

In a step 2102, a fiducial array may be placed in proximity of thepatient near the region of interest (ROI) in the anatomy. The region ofinterest may, for example, comprise a cancerous tumor or some otheranatomical structure that requires medical treatment. The fiducial arraymay be placed inside the scan field of view (FOV).

In a step 2103, the patient and fiducial array may be scanned with ascanner, producing typically a set of images indicating both the ROI inthe anatomy and the fiducials in the fiducial array. At this point, thepatient may be removed from the scanner as long as the relationshipbetween the fiducial array and patient can be preserved. In someinstances, it may be possible to remove the patient from the scan room(or other scanning location) entirely. For example, if the patient andfiducial array are mounted on a rigid overlay (e.g. “Standard Imaging(CT) Overlay”, Civco Medical Solutions, Coralville, Iowa), the patientand overlay may be removed from the scanner without disturbing the arrayor anatomy. This may be advantageous to reduce costs of occupying a MRor CT suite for an extended length of time.

In a step 2104, the images may be examined and the fiducials in thefiducial array may be located. Likewise, targets in the ROI may belocated and noted in the images (image space).

In a step 2105, using a priori knowledge of the location of fiducials onthe fiducial array, it is possible to determine the location andorientation of the fiducial array relative to the anatomy, in particularthe targets in the ROI. Because the template is designed to mate withthe fiducial array, the shape, location and orientation of the templateis known relative to the fiducial array (being related by transformationT1 above), and is thus also known relative to the anatomy. Accordingly,it is possible to display a “virtual template” in the images thatdepicts where the template would be located relative to the anatomy (andtargets therein) should it be attached. Additionally, it is possible todetermine the orientation and location of any other device rigidlyattached to the fiducial array as long as the attachment geometry andtransformation is known.

In one implementation, the fiducial array may also be designed to beremoved from its support arm, and a template may be attached to the armin a known relationship to the fiducial array that was removed andtaking care not to disturb its relationship to the anatomy. In thisinstance, the template's location is also known relative to thefiducials and therefore the anatomy, and a “virtual template” may begenerated.

In another implementation, the fiducial array may comprise a templateholder as previously described, and the template may comprise the platesthat are inserted into the plate holder. In this instance, thetemplate's location is also known relative to the fiducials andtherefore the anatomy, and a “virtual template” may be generated.

In a step 2106, the target locations and paths of the instruments may bedetermined. In the case of long cylindrical devices such as needles, thetarget points of the needle may be marked on the images of the anatomy,and a suitable path through the virtual template is generated. Once allpaths have been determined, a program for a CNC or rapid prototypingmachine may be generated and the virtual template may be manufactured toinclude the required holes or other features. Additional instrumentpaths may be generated to ensure accuracy of the template's manufactureand positioning. Such paths may, for example, be designed to direct aninstrument toward specific externally or internally located checkfiducials on or in the patient. An instrument when inserted through thetemplate will only touch the check fiducial if the template has beenmanufactured correctly, the planning step has been performed correctly,and the location of the template relative to the anatomy has remainedunchanged from the assumed position based on the fiducial array.

In a step 2107, the virtual template is manufactured into a physicaltemplate using any of the methods previously described herein. Themanufactured template may then be sterilized and prepared for inclusionin the surgical field. The depth of insertion may also be determined atthis time, and needle stops may be applied to the instruments (toprevent the needles from progressing too far into the tissue), or thecorrect depth recorded for the physician to consult.

In a step 2108, the template may be mounted to the fiducial array or armso that it is located in the same position as in the case of the virtualtemplate.

In a step 2109, instruments may be passed through the guide holes orpaths in the template. If the anatomy has not moved from the time of thescan, the instruments will go to the planned location in the anatomy.The patient may be rescanned at this point to determine if theinstruments have arrived at the correct locations. Once at the correctlocation, therapy may be applied.

Template Placed in Approximate Position and Paths Adjusted

According to an aspect of the invention, and with reference to FIGS.22-23 , it may be desirable in certain instances to quickly andapproximately position a template after a scan, and quickly generateaccurate path(s) to target(s). One non-limiting example of such aninstance may arise when a position sensor is available. Following thescan, a patient space location and anatomy may be determined relative toa position sensor frame of reference. This is registered with the imagedpositions of the targets and patient. A template holder (or templateframe) may then be placed roughly in an appropriate position to carryout the procedure, and its location determined in the same frame ofreference. Through the registration, the location of the template thatwould be attached to the template holder in image space is determined.The paths through the template between anatomy and the template may thenbe generated, and the template fabricated.

This aspect of the invention is illustrated in FIG. 22 . As shown,patient 2200 may be imaged using CT, MR, or other scanner. Patient 2200may be equipped with one or more fiducials 2201 attached directly to theskin, attached internally, or attached on separate object(s) fixedrelative to the anatomy of patient 2200. Patient 2200 may be imaged withthe one or more fiducials 2201 together with the anatomy. Fiducials 2201may be absent if another registration method is used.

In an implementation, if used, the locations of the one or morefiducials 2201 may also be determined in the coordinate system 2202 ofpatient 2200 through the use of, for example, position sensing system2203.

In one implementation, the tip of a tracked probe 2204 (e.g., adigitizing probe) may be touched to each fiducial 2201 in turn and itscoordinates recorded.

In yet another implementation, a tracking element 2205 may be attachedto (or otherwise integral with) one or more fiducials 2201. A singletracking element 2205 may serve one or multiple fiducials.Alternatively, tracking element 2205 may itself be used as a fiducial.Since the location of tracking element 2205 may be determined byposition sensing system 2203, and the location of the fiducials 2201 isknown relative to a position-indicating element (from the manufacturingdetails of the tracking element 2205), then the location of the one ormore fiducials 2205 are known in the coordinate system 2202 of positionsensing system 2203. Tracked fiducials such as these may also serve asdynamic references.

According to an aspect of the invention, fiducials may be used toregister image and patient space. For example, the locations offiducials may be determined in both coordinate systems (i.e., in imagespace and patient space), and a registration may be created between themso that any point in image space may be determined in patient space, orvice versa. Any previously-mentioned methods may also be used toregister image and patient space.

In one implementation, a template holder 2206 (or frame) may be placedin an approximate vicinity of one or more anatomical targets. This maybe done, for instance, after the imaging has taken place. Templateholder 2206 may be equipped with a position-indicating element (ortracker) 2207 rigidly attached to it. Position-indicating element 2207may be permanently affixed (or releasably coupled) to template holder2206. If the location of position-indicating element 2207 is knownrelative to the location of the template (secured by template holder2206), and the location of position-indicating element 2207 isdetermined by position sensing system 2203, then the location of thetemplate is also known in the coordinate system 2202 of the positionsensing system 2203. Using the transformation calculated duringregistration, the location and orientation of the virtual template maybe also determined in image space. It should be appreciated that thetemplate (secured by template holder 2206) may comprise a pair of plates(e.g., such as template 700), or may be formed from a single block(e.g., such as templates 400, 500, and 600 of FIGS. 4-6 , respectively).Further, in some implementations, template holder (or frame 2206) may beaffixed directly to patient 2200 in the desired location (e.g., using amedical adhesive or other known means of attachment). In alternativeimplementations, template holder (or frame 2206) may be maneuveredand/or secured in place using a mechanical (or other) support structureor mechanism similar to, for example, support mechanism 922 described indetail above with reference to FIG. 9 , or via another support structureor mechanism.

Alternatively, if fiducial features 2208 are present in known locationson template holder 2206, digitizing probe 2204 may be used to determinethe location of the template in the coordinate system of positionsensing system 2203.

This method enables the location and orientation of the template in theframe of reference of the images to be determined without it beingpresent during the scan.

As before, once the location of the template is known, the planningprocess may proceed and the intersection of the targets with thetemplate may be determined and the template manufactured and attached totemplate holder 2206.

It should be appreciated that one or more of the disclosedtemplate-locating techniques may be combined as in cases where a patientmoves, for example, and it becomes necessary to use a technique such asthat of FIG. 15 to realign it to the anatomy.

Although the foregoing has been described in terms of a customizedtemplate in which holes are drilled according to a physician plan, itshould be appreciated that a pre-formed template grid comprising aplurality of holes or other features may also be used. In this instance,control application 307 (of computer device 301) may be utilized toassist in selecting, among other things, the most appropriate of thepre-formed holes to use, and to what depth a needle (or otherinstrument) should be inserted. In this implementation, needles (orother devices) may be limited to the locations and directions that werealready drilled into the template, however any of a number of scenariosmay be implemented. In a first non-limiting example, the template couldbe aligned to a preselected position and orientation in which the holeshave been preselected. In a second non-limiting example, the template orfiducial array related to the template could be scanned with the patientand the correct holes could be selected following the scan. In a thirdnon-limiting example, the patient may be scanned with fiducials and thetemplate applied in an approximate location afterwards. The appropriateselection of holes may then be selected. While the exact placement ofthe needles may not be possible using this method, a sufficiently densegrid may provide sufficient coverage.

FIG. 23 is an exemplary flowchart of processing operations forregistering and manufacturing templates using the method described abovewith reference to FIG. 22 , according to an aspect of the invention. Theexemplary processing operations shown in FIG. 23 are performedintra-procedurally.

The described steps may be accomplished using some or all of the systemcomponents described in detail above and, in some implementations,various steps may be performed in different sequences and various stepsmay be omitted. Additional steps may be performed along with some or allof the steps shown in the depicted flow diagram. One or more steps maybe performed simultaneously. Accordingly, the steps as illustrated (anddescribed in greater detail below) are exemplary by nature and, as such,should not be viewed as limiting.

In step 2301, fiducials may be applied to a patient. The fiducials maycomprise passive fiducials or, as mentioned above, they may be attachedto (or otherwise integral with) a tracking element. In instances wherean alternate registration method is used, this step may be absent.

In step 2302, the patient anatomy and fiducials may be imaged in amanner comparable to step 1301 of FIG. 13 (described in detail above).

In step 2303, targets, fiducials (if present), and/or regions ofinterest may be annotated (e.g., by a physician or other individual) ina process similar to step 1302 of FIG. 13 (described in detail above).

In step 2304, regions of interest may be segmented in a manner similarto step 1303 of FIG. 13 (described in detail above).

In step 2305, registration may be performed using one of the methodsdiscussed previously. If fiducials are present, the location of thefiducials may be determined in image space (from step 2303) and inpatient space, and the registration calculations may be performed. Thelocation of the fiducials in patient space may be determined by samplingthem with a probe, or by using the built-in tracking capabilities of thefiducials together with the position sensing system.

In step 2306, a template frame may be placed in an approximate positionnear the target entry location, and locked in position.

In step 2307, the location of the frame may be determined by eitherdigitizing fiducial features on the template frame with a tracked probe,or by sampling the position indicating element fixed to the templateframe using the position sensing system.

In step 2308, the targets and needle trajectories may be determined. Theintersections with the template that will be attached to the templateframe are determined. This step is similar to step 1304 of FIG. 13(described in detail above), except that the virtual position of thetemplate is determined by the actual position of the template holder andcannot be adjusted once the template frame has been placed and locatedas per steps 2306 and 2307.

In step 2309, the template may be manufactured in a manner similar tostep 1305 of FIG. 13 (described in detail above).

In step 2310, the template may be sterilized in a manner similar to step1306 of FIG. 13 (described in detail above). The template may then befixed to the template frame in the position that the virtual templatewas assumed to be located.

In step 2311, a needle or instrument may be placed into the holes andits location verified by, for example, ultrasound, rescanning, orprobing the path to a check fiducial, etc.

In step 2312, a therapy may be deployed, or biopsy taken, as the needleis introduced into the patient to the target depth.

Needle for use with Templates

According to an aspect of the invention, and with reference to FIGS.24-25 , it may be desirable in certain instances to facilitate placementof a needle into a patient's anatomy where the needle is decoupled fromthe template (used to position the needle) so that free movement of thepatient's anatomy is not restricted by the needle. In mobile organs suchas the lung, for example, constraining movement with one or more needlesmay cause the tissue to tear.

In FIG. 24A, a composite needle assembly 2400 is depicted as comprisinga stylette 2401 and a cannula 2402. In one implementation, stylette 2401may be made of a solid material such as, for instance, a stainless steelor other material, and may include a hub 2403 comprised of plastic,metal, or another material.

As illustrated in FIG. 24B, stylette 2401 may narrow in diameter at apredetermined position along its length thereby creating a shoulder 2404that engages with cannula 2402 at a proximal (or first) end 2402 a ofcannula 2402. Although shoulder 2404 is depicted as being tapered on adiagonal, it should be appreciated that shoulder 2404 may alternativelybe “squared off” or perpendicular to the longitudinal axis of stylette2401.

Cannula 2402 may comprise a hollow tube that engages with stylette 2401when stylette 2401 is inserted there-through such that, when combined asshown in FIG. 24A, the diameter of the assembly equals that of cannula2402 alone. When engaged, a distal end of stylette 2401 may extendbeyond the distal end 2402 b of cannula 2402. In one implementation,stylette 2401 and cannula 2402 are configured to mate tightly (whenstylette 2401 is inserted through cannula 2402) so that they movesubstantially as a single unit until they are disengaged.

FIGS. 24C & 24D illustrate respective side and oblique views of astabilizing device 2405 that may be configured to be releasably coupledto cannula 2402, according to an aspect of the invention. Stabilizingdevice 2405 may include a cavity (or hole) 2408 that extends through theentire central, longitudinal (vertical) axis “A” of stabilizing device(e.g., to allow cannula 2402 or another tubular object to passcompletely there-through). Additionally, stabilizing device 2405 maycomprise a radial slot (or opening) 2410 that extends from central,longitudinal axis “A” radially outward along axis “B” (which isperpendicular to axis “A”) to form a cavity (or opening) that allowsstabilizing device 2405 to be placed on to cannula 2402 of needleassembly 2400 without having to thread needle assembly 2400 through it,even after needle assembly 2400 has been deployed through a template.Stabilizing device 2405 further comprises a restraining device 2407(e.g., a screw) to restrain cannula 2402 (of needle assembly 2400) inplace when it is inserted through hole 2408.

In one implementation, stabilizing device 2405 may additionally comprisean adhesive layer 2409 (e.g., such as double-sided tape) to adherestabilizing device 2405 to the skin of a patient.

FIG. 24E is an exemplary illustration of stabilizing device 2405 coupledto (cannula 2402 of) needle assembly 2400.

FIGS. 25A-25F are exemplary depictions illustrating the use of a needleassembly with a template during a guided interventional procedure,according to an aspect of the invention.

In FIG. 25A, a cross-section of a manufactured template 2501 is showncomprising a pair of plates (A, B) having an instrument trajectory orchannel 2502 extending there-through. It should be appreciated thatalthough template 2501 is depicted as comprising a pair of plates (e.g.,such as template 700), it may alternatively be formed from a singleblock (e.g., such as templates 400, 500, and 600 of FIGS. 4-6 ,respectively).

As shown in FIG. 25B, needle assembly 2503 (similar to that of needleassembly 2400 described above and illustrated in FIGS. 24A-24E) may beinserted through trajectory 2502 and through a patient's anatomy (e.g.,tissue) 2504 until a desired depth is obtained.

As depicted in FIG. 25C, a stabilizing device 2505 (similar to that ofstabilizing device 2405 described above and illustrated in FIGS.24C-24E) may be optionally coupled to (the cannula of) needle assembly2503.

As illustrated in FIG. 25D, the stylette of needle assembly 2503(similar to that of stylette 2401 described above and illustrated inFIGS. 24A, 24B, & 24E) may be removed, leaving cannula 2506 in place.

As shown in FIG. 25E, template 2501 may be removed.

As depicted in FIG. 25F, a therapy or biopsy needle 2507 (or othersimilar device) may be inserted. Once the procedure is complete, thetherapy/biopsy needle 2507, stabilizing device 2505, and cannula 2506may be removed.

Other implementations, uses and advantages of the invention will beapparent to those skilled in the art from consideration of thespecification and practice of the invention disclosed herein. Thespecification should be considered exemplary only.

What is claimed is:
 1. A method of performing a guided interventionalmedical procedure using a template, the method comprising: obtaining atleast one medical image of a patient's anatomy, the at least one medicalimage including at least one anatomical target; generating, via acomputer device, a virtual template that is positioned and oriented at aplanned location relative to the at least one anatomical target on theat least one medical image, wherein the virtual template comprises atleast one channel passing there-through along a trajectory determined tointersect with the at least one anatomical target; and causing aphysical template to be manufactured that replicates the virtualtemplate, the physical template comprising: (i) a template body, and(ii) at least one template channel that replicates the at least onechannel of the virtual template, and that enables passage of a medicaldevice through the template body; wherein the template body comprises: afirst plate and a second plate separated by at least one spacer, thefirst plate comprising a first side of the template body that includesan entrance of the at least one template channel, and the second platecomprising a second side of the template body that includes an exit ofthe at least one template channel.
 2. The method of claim 1, furthercomprising: aligning the physical template to the patient's anatomy, inaccordance with the planned location of the virtual template, for use inthe guided interventional medical procedure.
 3. The method of claim 2,further comprising: positioning a fiducial array, comprising one or morediscrete fiducials, in proximity of the patient's anatomy; anddetermining the planned location relative to the fiducial array and theat least one anatomical target through a registration process.
 4. Themethod of claim 3, wherein aligning the physical template to thepatient's anatomy comprises: mounting the physical template to thefiducial array.
 5. The method of claim 4, further comprising: verifyingalignment of the physical template using the one or more discretefiducials as targets.
 6. The method of claim 3, wherein aligning thephysical template to the patient's anatomy comprises: replacing thefiducial array with the physical template.
 7. The method of claim 3,wherein the registration process comprises at least one of:point-to-point registration in which at least one second medical imageis compared with the at least one medical image; surface registration inwhich a cloud of points is obtained in the patient's anatomy and matchedwith a surface model of the same region in the at least one medicalimage; automatic registration in which the fiducial array isautomatically identified in the at least one medical image by thecomputer device; or ultrasound registration in which targets identifiedin a pre-operative ultrasound image are represented on the least onemedical image.
 8. The method of claim 3, wherein the registrationprocess comprises: using locations of one or more discrete fiducials inimage space together with a position sensor to determine locations ofthe one or more discrete fiducials in patient space by using a probewith an incorporated position-indicating element, or through knowledgeof the relationship of the one or more fiducials to one or moreposition-indicating elements.
 9. The method of claim 3, wherein the oneor more discrete fiducials comprise at least one of: one or more of skinfiducials; a distinctively shaped object; objects with applied ballsthat are distinctly visualized on the imaging means; distinct paths; orinternal fiducials both naturally occurring and implanted includingBB's, catheters, needles, or vessels.
 10. The method of claim 3, whereinthe fiducial array comprises a support structure for the physicaltemplate.
 11. The method of claim 3, the registration process comprisesmathematically mapping position data of position indicating elements ofa patient space expressed in terms a coordinate system of a trackingdevice to an image space expressed in a coordinate system of externallyimaged data, determined at a time when the at least one image is taken.12. The method of claim 1, wherein the obtained at least one medicalimage of the patient's anatomy comprises at least one of: an X-Rayimage; a Magnetic Resonance imaging (MRI) image; a Computed Tomography(CT) image; an ultrasound image; or a Positron Emission Tomography (PET)image.
 13. The method of claim 1, further comprising: annotating the atleast one anatomical target on the at least one medical image.
 14. Themethod of claim 1, wherein the template body comprises a solid body. 15.The method of claim 1, wherein causing a physical template to bemanufactured comprises: causing the physical template to be manufacturedat the time of the guided interventional medical procedure.
 16. Themethod of claim 1, wherein causing a physical template to bemanufactured further comprises: causing the physical template to bemanufactured using at least one of a Computer Numerical Control (CNC)machine, or a three-dimensional (3D) printer.
 17. The method of claim 1,further comprising: passing the medical device through the at least onetemplate channel of the physical template during the guidedinterventional medical procedure.
 18. The method of claim 1, the methodfurther comprising: displaying, by the computer device, a depiction ofthe virtual template in the at least one medical image that indicateswhere the physical template would be located relative to the patient'sanatomy.
 19. The method of claim 3, the method further comprising:removing the fiducial array from where it was positioned in proximity tothe patient's anatomy after obtaining the at least one medical image.20. The method of claim 1, further comprising: calculating aregistration transformation to bring markers in a patient space intocoincidence with the same markers in an image space.